Feedback

Acute Necrotizing Mediastinitis

James E. Speicher, Mark D. Iannettoni
Acute Necrotizing Mediastinitis is a topic covered in the Pearson's General Thoracic.

To view the entire topic, please or .

STS Cardiothoracic Surgery E-Book from The Society of Thoracic Surgeons provides expert guidance for Cardiac and Thoracic Surgery. Sections include Pearson’s General Thoracic, Esphageal, Adult Cardiac, and Pediatric and Congenital Cardiac Surgery. Explore these free sample topics:

-- The first section of this topic is shown below --

Key Points

  • Acute necrotizing mediastinitis is a destructive, life-threatening condition akin to necrotizing fasciitis and acute necrotizing pancreatitis.
  • Generally arising from an oropharyngeal source, the infection is a polymicrobial mix of aerobes and anaerobes that act synergistically.
  • Diagnostic delay and inadequate surgical drainage lead to inordinate mortality.
  • The cornerstones of diagnosis and treatment include immediate administration of broad-spectrum antibiotics, early contrast-enhanced cervicothoracic CT scanning, and aggressive surgical therapy aimed at both the neck and mediastinum.
  • Best results are achieved by a multidisciplinary approach including thoracic surgeons, otolaryngologists, and, with odontogenic infection, oral maxillofacial surgeons.
  • Unless mediastinal involvement is minimal and located above the carina, a thoracic approach must supplement the cervical approach, and serial operations may be required.
  • Tracheostomy is often necessary but should be used selectively.
  • The use of minimally invasive drainage procedures are controversial, but recent studies indicate that thoracoscopy may be appropriate in some cases.

Acute necrotizing mediastinitis (ANM), also known as descending necrotizing mediastinitis, is a life-threatening condition. Without timely diagnosis and aggressive surgical management, fatal outcome is likely. Surgical mortality exceeded 50% in the preantibiotic era (Pearse, 1938),[1] but even after availability of broad-spectrum antibiotics, mortality still approached 40% (Estrera et al, 1983).[2] Introduction of contrast medium-enhanced cervicothoracic computed tomography (CT) led to improved outcomes by facilitating diagnosis and directing operative therapy. Mortality reported in case series of two or more patients published from 1990 to present has decreased markedly (Table 1). Most recent reports attribute successful management of ANM to earlier diagnosis via improved imaging techniques, immediate institution of appropriate antibiotics, and prompt aggressive surgery with mandatory cervical and/or transthoracic drainage. However, debate remains as to whether transthoracic surgical intervention, as well as tracheostomy, should be compulsory.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]

Table 1: Acute Necrotizing Mediastinitis Case Series: 1990-2016

Surgical Treatment

Author (Year)

Mean Age

No.

M : F

Cervicotomy

Thoracotomy/Thoracoscopy

Tracheostomy

Survival (%)

Wheatley et al[12] (1990)

33

2

2 : 0

2

2

2

100%

Marty-Ane et al[8] (1994)

49

6

6 : 0

6

6

NA

83%

Brunelli et al[3] (1996)

44

5

5 : 0

5

2

2

100%

Ris et al[11] (1996)

35

3

1 : 2

3

3

0

67%

Casanova et al[13] (1996)

< 35*

2

2 : 0

2

2

0

100%

Corsten et al[5] (1997)

46

8

5 : 3

8

6

1

88%

Kiernan et al[7] (1998)

56

5

2 : 3

5

1

4

100%

Marty-Ane et al[9] (1999)

42

12

11 : 1

12

11

NA

83%

Freeman et al[6] (2000)

38

10

9 : 1

10

10

4

100%

Papalia et al[14] (2001)

39

13

9 : 4

13

11

4

77%

Mihos et al[10] (2004)

55

6

2 : 4

6

6

1

83%

Makeieff et al[15] (2004)

42

17

16 : 1

17

14

0

82%

Son et al[16] (2006)

51

9

6 :3

9

9

2

89%

Cho et al[17] (2008)

52

17

8 :9

13

15

0

80%

Ridder et al[18] (2010)

52

45

33 :12

44

7

28

89%

Karkas et al[19] (2010)

54

17

12 :5

17

7

15

94%

Kocher et al[20] (2012)

48

17

8 :9

11

16

9

94%

D’Cunha et al[21](2013)

33

8

5 :3

6

6

0

100%

Dajer-Fadel et al[22](2014)

41

60

43 :17

49

60

47

65%

Cumulative

46*

262

185 : 77

238

194

119

83%

*Age of one “young” patient was not included in the manuscript.

Values were not included in the respective publications.

M : F, male : female ratio.

ANM generally results from odontogenic, peritonsillar, or other pharyngeal infections (Brunelli et al, 1996).[3],[5],[6],[7],[8],[10],[12] It may also result from iatrogenic oropharyngeal perforation, cervical trauma, epiglottitis, parotitis, sinusitis, sternoclavicular joint infection, and illicit intravenous drug administration.[3],[12],[15] Cervical esophageal perforation, iatrogenic or otherwise, is thought to represent a distinct condition with a less virulent course.[12] Although neck exploration with cervical drainage and operative esophageal repair may be required, progression of disease into the mediastinum, with necrosis, is unusual. Also, ANM must not be confused with generally less threatening mediastinal infections, such as primary abscess, which lack the descending, necrotizing process in which oral flora have become pathogenic. In comparing reports on efficacy of surgical procedures for ANM, it is imperative to verify that patients meet the criteria outlined by Estrera and colleagues in their 1983 report (Table 2).[2]

Table 2: Estrera and Colleagues’ Criteria for Acute Necrotizing Mediastinitis

1. Clinical manifestations of severe oropharyngeal infection

2. Demonstration of characteristic roentgenographics features of mediastinitis

3. Documentation of the necrotizing mediastinal infection at operation or postmortem examination or both

4. Establishment of the relationship of oropharyngeal infection with the development of the necrotizing mediastinal process

Data from Estrera AS, Landay MJ, Grisham JM, et al: Descending necrotizing mediastinitis. Surg Gynecol Obstet 157:545-552, 1983.

-- To view the remaining sections of this topic, please or --

Key Points

  • Acute necrotizing mediastinitis is a destructive, life-threatening condition akin to necrotizing fasciitis and acute necrotizing pancreatitis.
  • Generally arising from an oropharyngeal source, the infection is a polymicrobial mix of aerobes and anaerobes that act synergistically.
  • Diagnostic delay and inadequate surgical drainage lead to inordinate mortality.
  • The cornerstones of diagnosis and treatment include immediate administration of broad-spectrum antibiotics, early contrast-enhanced cervicothoracic CT scanning, and aggressive surgical therapy aimed at both the neck and mediastinum.
  • Best results are achieved by a multidisciplinary approach including thoracic surgeons, otolaryngologists, and, with odontogenic infection, oral maxillofacial surgeons.
  • Unless mediastinal involvement is minimal and located above the carina, a thoracic approach must supplement the cervical approach, and serial operations may be required.
  • Tracheostomy is often necessary but should be used selectively.
  • The use of minimally invasive drainage procedures are controversial, but recent studies indicate that thoracoscopy may be appropriate in some cases.

Acute necrotizing mediastinitis (ANM), also known as descending necrotizing mediastinitis, is a life-threatening condition. Without timely diagnosis and aggressive surgical management, fatal outcome is likely. Surgical mortality exceeded 50% in the preantibiotic era (Pearse, 1938),[1] but even after availability of broad-spectrum antibiotics, mortality still approached 40% (Estrera et al, 1983).[2] Introduction of contrast medium-enhanced cervicothoracic computed tomography (CT) led to improved outcomes by facilitating diagnosis and directing operative therapy. Mortality reported in case series of two or more patients published from 1990 to present has decreased markedly (Table 1). Most recent reports attribute successful management of ANM to earlier diagnosis via improved imaging techniques, immediate institution of appropriate antibiotics, and prompt aggressive surgery with mandatory cervical and/or transthoracic drainage. However, debate remains as to whether transthoracic surgical intervention, as well as tracheostomy, should be compulsory.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]

Table 1: Acute Necrotizing Mediastinitis Case Series: 1990-2016

Surgical Treatment

Author (Year)

Mean Age

No.

M : F

Cervicotomy

Thoracotomy/Thoracoscopy

Tracheostomy

Survival (%)

Wheatley et al[12] (1990)

33

2

2 : 0

2

2

2

100%

Marty-Ane et al[8] (1994)

49

6

6 : 0

6

6

NA

83%

Brunelli et al[3] (1996)

44

5

5 : 0

5

2

2

100%

Ris et al[11] (1996)

35

3

1 : 2

3

3

0

67%

Casanova et al[13] (1996)

< 35*

2

2 : 0

2

2

0

100%

Corsten et al[5] (1997)

46

8

5 : 3

8

6

1

88%

Kiernan et al[7] (1998)

56

5

2 : 3

5

1

4

100%

Marty-Ane et al[9] (1999)

42

12

11 : 1

12

11

NA

83%

Freeman et al[6] (2000)

38

10

9 : 1

10

10

4

100%

Papalia et al[14] (2001)

39

13

9 : 4

13

11

4

77%

Mihos et al[10] (2004)

55

6

2 : 4

6

6

1

83%

Makeieff et al[15] (2004)

42

17

16 : 1

17

14

0

82%

Son et al[16] (2006)

51

9

6 :3

9

9

2

89%

Cho et al[17] (2008)

52

17

8 :9

13

15

0

80%

Ridder et al[18] (2010)

52

45

33 :12

44

7

28

89%

Karkas et al[19] (2010)

54

17

12 :5

17

7

15

94%

Kocher et al[20] (2012)

48

17

8 :9

11

16

9

94%

D’Cunha et al[21](2013)

33

8

5 :3

6

6

0

100%

Dajer-Fadel et al[22](2014)

41

60

43 :17

49

60

47

65%

Cumulative

46*

262

185 : 77

238

194

119

83%

*Age of one “young” patient was not included in the manuscript.

Values were not included in the respective publications.

M : F, male : female ratio.

ANM generally results from odontogenic, peritonsillar, or other pharyngeal infections (Brunelli et al, 1996).[3],[5],[6],[7],[8],[10],[12] It may also result from iatrogenic oropharyngeal perforation, cervical trauma, epiglottitis, parotitis, sinusitis, sternoclavicular joint infection, and illicit intravenous drug administration.[3],[12],[15] Cervical esophageal perforation, iatrogenic or otherwise, is thought to represent a distinct condition with a less virulent course.[12] Although neck exploration with cervical drainage and operative esophageal repair may be required, progression of disease into the mediastinum, with necrosis, is unusual. Also, ANM must not be confused with generally less threatening mediastinal infections, such as primary abscess, which lack the descending, necrotizing process in which oral flora have become pathogenic. In comparing reports on efficacy of surgical procedures for ANM, it is imperative to verify that patients meet the criteria outlined by Estrera and colleagues in their 1983 report (Table 2).[2]

Table 2: Estrera and Colleagues’ Criteria for Acute Necrotizing Mediastinitis

1. Clinical manifestations of severe oropharyngeal infection

2. Demonstration of characteristic roentgenographics features of mediastinitis

3. Documentation of the necrotizing mediastinal infection at operation or postmortem examination or both

4. Establishment of the relationship of oropharyngeal infection with the development of the necrotizing mediastinal process

Data from Estrera AS, Landay MJ, Grisham JM, et al: Descending necrotizing mediastinitis. Surg Gynecol Obstet 157:545-552, 1983.

There's more to see -- the rest of this entry is available only to subscribers.

Last updated: January 5, 2021