DESCENDING NECROTIZING MEDIASTINITIS - ADVANTAGE OF MEDIASTINAL DRAINAGE WITH THORACOTOMY

Descending necrotizing mediastinitis can occur as a complication of or opharyngeal and cervical infections that spread to the mediastinum via the cervical spaces. Delayed diagnosis and inadequate mediastinal dra inage through a cervical or minor thoracic approach are the primary ca uses of a high published mortality rate (near 40%). Between 1985 and 1 992, six men (mean age, 49 years) with descending necrotizing mediasti nitis were surgically treated at our institution. The primary orophary ngeal infection was peritonsillar abscess (three cases) and odontogeni c abscess (three cases). In all cases, occurrence of respiratory insuf ficiency associated,vith serious cervical infection suggested the medi astinitis diagnosis. Computed tomographic scans confirmed the mediasti nitis, showing mediastinal abscess and mediastinal emphysema. Ah patie nts underwent surgical drainage of the deep neck infection combined wi th mediastinal drainage through a thoracic approach. The outcome was f avorable in five patients who had mediastinal drainage through a thora cotomy; the patient who had mediastinal drainage through a minor thora cic approach (anterior mediastinotomy) died of tracheal fistula on pos toperative day 18, In our experience, aggressive mediastinal drainage by a thoracotomy approach regardless of the level of mediastinal invol vement led to improvement in survival of these patients, with a 17% mo rtality rate.