Management of descending necrotizing mediastinitis

Background. Descending necrotizing mediastinitis (DNM) is uncommon, and may be lethal if not treated adequately and promptly. Delayed diagnosis of the disease is sometimes encountered in clinical practice. Methods. Eight consecutive patients with acute DNM were identified between 1991 and 1995, including five men and three women. The mean age was 45.8 years (range, 22- 71 years). The infectious sources consisted of six esophageal perforations, one cervical cutting injury and one tonsillitis. The clinical presentations were evaluated. Diagnostic procedures including chest radiograph, sonogram and computerized tomography scans of the chest and neck were examined. Diagnosis and treatment, including culture results from drained fluids and debrided tissues, and antibiotic and supportive therapies were reviewed. Results. Six patients who underwent aggressive surgical treatment recovered well. Two patients who received supportive treatment died of sepsis alone. The cultured bacteria included: Klebsiella oxytoca, Staphylococcus aureus, Trichosporum and other mixed oral cavity flora. Conclusions. Early diagnosis and adequate antibiotic and support therapies are essential to achieve good patient outcomes in acute descending mediastinitis. Adequate drainage and debridement, appropriate antibiotic therapy, and sufficient nutritional and respiratory support are the main treatment elements.