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Descending necrotizing mediastinitis: Cervicotomy or thoracotomy?

1996; Elsevier BV; Volume: 111; Issue: 2 Linguagem: Inglês

10.1016/s0022-5223(96)70460-9

1097-685X

Alessandro Brunelli, Armando Sabbatini, Giovanbattista Catalini, A Fianchini,

Tracheal and airway disorders

In a former issue of the Journal, Marty-Ane and colleagues1Marty-Ane CH Alauzen M Alric P Serres-Cousine O Mary H Descending necrotizing mediastinitis advantage of mediastinal drainage with thoracotomy.J THORAC CARDIOVASC SURG. 1994; 107: 55-61PubMed Google Scholar emphasized the importance of thoracotomy in descending necrotizing mediastinitis (DNM). They considered cervicotomy alone insufficient for adequate mediastinal drainage. Recently, we had a case of DNM at our institution. This condition was successfully treated through a transcervical approach. A 49-year-old man with carious teeth was admitted with a painful swollen neck (anterolateral on the right side), trismus, and high fever. Examination revealed brawny edema and tenderness of the right side of the neck, extending downward to the right shoulder and right arm. Subcutaneous emphysema was present. A chest roentgenogram showed gas in the soft tissue of the neck and a widened mediastinum, along with bilateral pleural effusion. A cervicothoracic computed tomographic scan that was immediately obtained revealed soft-tissue infiltration with gas bubbles in the right side of the neck, with involvement of the right supraclavicular region and fascial planes of the right arm. Fluid and air were seen in the anterior part of the mediastinum, along with bilateral pleural effusion; this was suggestive of mediastinitis. The patient was promptly taken to the operating room, where he underwent a right third mandibular molar odontectomy and transcervical drainage of the right and left compartments of the neck, as well as of the anterior mediastinum, through a bilateral and anterior cervicotomy. Incisions over the right clavicle and along the medial side of the right arm were also performed to drain these regions. After extensive drainage and débridement, wounds were kept packed open to facilitate drainage of pus and frequent irrigation. Cultures revealed Staphylococcus aureus, and immediate intravenous therapy with imipenem (500 mg every 4 hours) and vancomycin (2 gm) was started on the basis of sensitivity studies. On postoperative day 3, a chest roentgenogram showed a worsening of the left pleural effusion, necessitating a chest-tube thoracostomy. After the first surgical drainage, the patient was taken to the operating room another six times for secondary exploration, débridement, and partial suture of the wounds. His condition slowly improved and his temperature became normal, the chest tube was removed, and the patient was discharged on postoperative day 30 without physical or roentgenographic signs of mediastinitis. Mediastinitis occasionally occurs as a consequence of oropharyngeal infection. Because of its rapid spread along cervical fascial planes—as well as through them—and its almost always delayed diagnosis, DNM is regarded as the most lethal form of mediastinitis.2Pearse HE. Mediastinitis following cervical suppuration.Ann Surg. 1938; 108: 588-611Crossref PubMed Google Scholar Even in the antibiotic era, mortality rates are as high as 40%.3Estrera AS Landay MJ Grisham JM et al.Descending necrotizing mediastinitis.Surg Gynecol Obstet. 1983; 157: 545-552PubMed Google Scholar Marty-Ane and associates1Marty-Ane CH Alauzen M Alric P Serres-Cousine O Mary H Descending necrotizing mediastinitis advantage of mediastinal drainage with thoracotomy.J THORAC CARDIOVASC SURG. 1994; 107: 55-61PubMed Google Scholar reported a survival of 83% among six patients treated at their institution for DNM. They recommended transthoracotomy mediastinal drainage without attempting transcervical drainage alone, regardless of the level of involvement into the mediastinum. Our case demonstrated that transcervical drainage, if performed without delay, may be successful in treating patients with DNM, even complicated by pleural effusion and necrotizing fascitis of the right arm, as long as the infection is limited to the superior mediastinum above the carina, as advocated by Estrera and associates.3Estrera AS Landay MJ Grisham JM et al.Descending necrotizing mediastinitis.Surg Gynecol Obstet. 1983; 157: 545-552PubMed Google Scholar Because the level of involvement of the mediastinum depends on the interval between the onset of the primary cervical infection and the recognition of the mediastinitis, we think that the outcome of DNM is strictly dependent on the delay of diagnosis. If the process is promptly recognized, we believe that thoracotomy may not be necessary. We strongly advocate the early use of cervicothoracic computed tomographic scan in every case of laterocervical infection, because plain chest roentgenograms may be not diagnostic until the process has diffusely spread into the mediastinum. In the era before computed tomographic scanning, we treated at our institution a patient with DNM caused by perforation of the hypopharynx for difficult endotracheal intubation. Before the diagnosis of DNM was made the patient, a 24-year-old man, underwent cervicotomy for drainage of the cervical infection, bilateral tube thoracostomy for drainage of pleural effusion, and subxiphoid drainage for treatment of cardiac tamponade. Chest roentgenograms did not show any sign of mediastinal involvement until 8 days after the onset of the primary infection, when the process had spread well into the mediastinum. Cervicomediastinal drainage through a lateral and anterior cervicotomy proved insufficient, and a right thoracotomy was necessary. Foul-smelling, purulent material was drained from well below the fourth thoracic vertebra posteriorly, indicative of a critical delay in the diagnosis. After thoracotomy, the patient's condition improved, and he was discharged on postoperative day 28 without sequelae. Although Marty-Ane and colleagues1Marty-Ane CH Alauzen M Alric P Serres-Cousine O Mary H Descending necrotizing mediastinitis advantage of mediastinal drainage with thoracotomy.J THORAC CARDIOVASC SURG. 1994; 107: 55-61PubMed Google Scholar reported an unfavorable outcome in the only patient who did not undergo thoracotomy, it would be interesting to know the delay between onset of primary infection and diagnosis for each patient in their series. They reported a range of 6 to 20 days. In conclusion, we consider the systematic use of thoracotomy in DNM, as suggested by Marty-Ane and associates,1Marty-Ane CH Alauzen M Alric P Serres-Cousine O Mary H Descending necrotizing mediastinitis advantage of mediastinal drainage with thoracotomy.J THORAC CARDIOVASC SURG. 1994; 107: 55-61PubMed Google Scholar inappropriate. We support the less aggressive conclusions of Estrera and colleagues,3Estrera AS Landay MJ Grisham JM et al.Descending necrotizing mediastinitis.Surg Gynecol Obstet. 1983; 157: 545-552PubMed Google Scholar who recommend transthoracotomy approach only if the mediastinitis has spread below the tracheal bifurcation anteriorly or the fourth thoracic vertebra posteriorly.