Descending necrotizing mediastinitis: Description, Causes and Risk Factors:Abbreviation: DNM.Descending necrotizing mediastinitis (DNM) is an uncommon, serious and fulminant form of mediastinitis which is the result of spread of a severe cervical infection down to the mediastinum.The most common causes of Descending necrotizing mediastinitis are odontogenic infections, peritonsilar and retropharyngeal abscesses. Traumatic pharyngeal perforations by foreign bodies (fish or chicken bones), iatrogenic pharyngeal perforations and Ludwig angina are other, rare causes of DNM. Descending necrotizing mediastinitis is in most cases a mixed infection from aerobic and anaerobic species, although aerobic ?-hemolytic streptococcus may be the only responsible microorganism. In mixed aerobic and anaerobic infections, the symbiosis between one or more species of microorganisms results in a synergistic necrotizing cellulites and multiple small vessel thrombosis that becomes clinically evident within 24-72 hours after the onset of a deep cervical infection or following an odontogenic procedure. The commonest microorganisms found in Descending necrotizing mediastinitis are aerobic and anaerobic streptococci, Fusobacterium, Bacteroides species, Staphylococci, Haemophilus species, Clostridium perfringens, Escherichia coli and Pseudomonas aeruginosa.Descending necrotizing mediastinitis is a relatively rare condition and it is accompanied by high mortality rates, especially if diagnosis and treatment are delayed for more than 24 hours after the onset of symptoms. The rarity of the disease and the non-specific symptoms in the early phase of mediastinal involvement are responsible for the late recognition in most cases. The available information concerning diagnosis and treatment come from relatively small case series, and consequently no standard form of treatment exists. The disease predominantly affects young men.Treatment of Descending necrotizing mediastinitis consists of intravenous broad spectrum antibiotics therapy with adequate surgical drainage of the cervical and mediastinal collections and extensive debridement and excision of necrotic tissue.Symptoms:Symptoms and signs of mediastinal involvement include substernal and pleuritic pain, dysphagia, dyspnea, signs of pleural and/or pericardial effusion and septic shock.Diagnosis:The diagnosis of mediastinal involvement is often delayed and in many patients the diagnosis will be made after the deterioration of their general condition because of sepsis.Diagnosis may include:Clinical manifestations of severe infection.
Demonstration of characteristic radiographic featuressuch as mediastinal widening, mediastinal emphysema, mediastinal fluid collection with bubbles or abscesses with air fluid level.
Documentation of necrotizing mediastinal infection at operation or post-mortem examination or both.
Establishment of the relationship of oropharyngeal or cervical infection with the development of the necrotizing mediastinal process.
CT scan of the chest and neck is an important examination in any patient who is treated for a deep cervical infection in order to early recognize the presence of mediastinal involvement. CT scan shows soft tissue infiltration with loss of the normal appearance of mediastinal fat (increased density), mediastinal emphysema and mediastinal fluid collections with or without air bubbles. Pleural and pericardial effusions can also be demonstrated.Treatment:Many different approaches are reported for mediastinal drainage in Descending necrotizing mediastinitis, according to the level of mediastinitis diffusion.Aggressive cervical and mediastinal debridement and drainage, effective pleural and pericardial drainage, administration of broad spectrum antibiotics, covering both aerobes and anaerobes, and support of the vital organs in the ICU are the four important parameters for the treatment of DNM.The different surgical approaches which are reported in the literature to drain the mediastinum in Descending necrotizing mediastinitis are the following:Transcervical drainage plus thoracotomy.
Transcervical drainage plus median sternotomy.
Transcervical drainage plus VATS.
Transcervical drainage plus bilateral thoracotomy.
Transcervical drainage plus Clamshell incision.
Transcervical drainage plus bilateral or unilateral anterior mediastinotomy.
Transcervical drainage plus subxiphoid drainage.
Transcervical drainage alone only for type I DNM.
NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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