Clinical Study

Ear, Nose & Throat Journal

2021, Vol. 100(5) 350–353
Descending Necrotizing Mediastinitis: ª The Author(s) 2020
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Analysis of 9 Cases in Our Hospital DOI: 10.1177/0145561320933964
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Peng Wu, MS1 , Fan Ye, MS1, Ziheng Zhang, MS1, Linghao Zhang, MS1,
Hailiang Lin, MS1, Fei Ye, MS1, Zai Zhuang, MS1, Renyu Lin, MS1, Min Ye, MS2,
Xiaoming Lin, MD3, and He Li, MD1

Abstract
Objectives: Descending necrotizing mediastinitis (DNM) is a serious and progressive infection involving the neck and chest and
with high mortality if not treated quickly and properly. The aim of this study is to share our practices for managing this condition.
Methods: We retrospectively evaluated 9 patients diagnosed with DNM in our hospital between January 2006 and October
2019. Age, gender, origin of infection, length of hospital stay, microorganisms present, type of surgical treatment, and clinical
outcomes were reviewed. Results: All patients underwent surgery to drain neck and mediastinal secretions and collections.
Three (33.3%) patients were treated with transcervical drainage alone, and 6 (66.7%) patients were treated with combined
transcervical and transthoracic drainage. Reoperations were reported in 3 (33.3%) cases. The average length of hospital stay was
22.78 + 10.05 days (range: 9-40 days). The average length of intensive care unit stay was 6.44 + 10.10 days (range: 0-25 days).
There were no in-hospital deaths, and all patients were discharged home with good outcomes. Conclusions: To improve the
prognosis of DNM, we suggest early and adequate debridement of all affected areas along with the proper use of antibiotics. A
multidisciplinary approach involving both cardiothoracic and ENT surgeons is also required.

Keywords
descending necrotizing mediastinitis, transcervical drainage, transthoracic drainage, video-assisted thoracic surgery

Introduction clinical outcomes were reviewed. The total follow-up duration

was at least 3 months.
Descending necrotizing mediastinitis (DNM) is a serious and
We evaluated all patients with preoperative computed
progressive infection involving the neck and chest with high
tomography (CT) scan to establish the diagnosis. The type
mortality if not treated quickly and properly,1 and thorough
of DNM was classified according to the criteria of Endo
surgical debridement at the earliest opportunity is essential for
et al3 as type 1 ¼ infection above the carina and type 2 ¼
good prognosis. Here, we review our 13-year experience of
infection below the tracheal bifurcation, which is further sub-
managing this condition in our hospital.
divided into type 2A (lower anterior mediastinum) and type

Patients and Methods

1
Department of Otolaryngology, The First Affiliated Hospital of Wenzhou
We retrospectively evaluated a total of 9 patients diagnosed
Medical University, Wenzhou, Zhejiang, China
with DNM in our hospital between January 2006 and October 2
Department of Pneumology, The First Affiliated Hospital of Wenzhou
2019. The following diagnostic criteria for DNM were estab- Medical University, Wenzhou, Zhejiang, China
lished by Estrera et al2: (1) clinical manifestations of severe 3
Department of Cardiothoracic Surgery, The First Affiliated Hospital of
oropharyngeal or cervical infection, (2) demonstration of char- Wenzhou Medical University, Wenzhou, Zhejiang, China
acteristic radiographic features of mediastinitis, (3) surgical or Received: March 31, 2020; revised: May 20, 2020; accepted: May 21, 2020
postmortem evidence of DNM, and (4) correlation between
Corresponding Author:
oropharyngeal/cervical infection and the development of He Li, Department of Otolaryngology, The First Affiliated Hospital of
DNM. Age, gender, origin of infection, length of hospital stay, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
microorganisms present, type of surgical treatment, and Email: [email protected]

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Wu et al 351

Figure 1. A-C, Axial computed tomography (CT) of the neck and chest before surgery. Air was observed in the neck and mediastinum (A and B,
white arrow), and pulmonary infection was observed (C). D, Intraoperative view of necrotic tissue within the neck. E, The cervical incision was
left open for 9 days. F, Iodoform gauze (black arrow) within the cervical incision. G, The use of an indwelling thoracic drainage tube (white
arrow). H, Infection of the cervical incision was controlled. I, Secondary closure of the cervical incision. J-L, Axial CT of the neck and chest after
surgery. The radiological findings were obviously improved.

2B (lower posterior mediastinum). All the work didn’t anaerobic bacteria (n ¼ 1), actinomyces (n ¼ 1), and Stenotro-
involve the use of animal or human subjects. And there is phomonas maltophilia (n ¼ 1). No microorganisms could be
no identification of patients. identified in the other 6 patients.
All patients underwent surgery to drain neck and mediast-
inal secretions and collections. Of these 9 patients, 3 (33.3%)
Data Analysis patients were treated with transcervical drainage alone, and 6
Statistical analysis was performed using SPSS 22.0. Data were (66.7%) patients were treated with combined transcervical
expressed as the mean + standard deviation. and transthoracic drainage. Video-assisted thoracic surgery
(VATS) was performed in 3 (50%) of these 6 patients. Reo-
perations were reported in 3 (33.3%) of the 9 cases. An
Results indwelling thoracic drainage tube was used in all patients, and
All patients presented with typical symptoms, histories, and a washing tube was used in 3 of them. The cervical incision
radiological findings. There were 6 (66.7%) male and 3 was left open followed by secondary closure in 1 patient
(33.3%) female patients, with a mean age of 44.33 + 13.54 (Figure 1) due to severe tissue necrosis. Only 2 (22.2%)
years (range: 23-64 years). Of these 9 patients, 3 (33.3%) patients underwent tracheotomy for airway compromise (pre-
patients were diagnosed with diabetes. Primary pathology was surgical, outside the hospital) and for long-term treatment
odontogenic (n ¼ 3), parapharyngeal (n ¼ 3), tonsillar infection after surgery. The average length of hospital stay was 22.78
(n ¼ 2), and cervical infection (n ¼ 1). Seven (77.8%) patients + 10.05 days (range: 9-40 days). The average length of inten-
were type 1 and 2 (22.2%) patients were type 2. sive care unit stay was 6.44 + 10.10 days (range: 0-25 days).
Blood tests and microbiological assessment of secretions There were no in-hospital deaths, and all patients were dis-
and tissues were performed in all patients. Broad-spectrum charged home with good outcomes. The patients’ first seen
antibiotics were used in all patients immediately upon presen- time after hospital discharge ranged from 7 to 14 days. The
tation at the hospital and subsequently adjusted according to clinical characteristics of the patients and the surgical
the results of the cultures. Identified microorganisms were approaches are summarized in Table 1. A typical case is
detected in 3 patients, including Gram-positive combined with shown in Figure 1.
352 Ear, Nose & Throat Journal 100(5)

Table 1. Clinical Characteristics of Patients and the Surgical Approaches.

Case number Age/gender DNM type Surgical procedure Numbers of operations Origin of infection Tracheotomy

1 23/M 1 Transcervical and right VATS 1 Odontogenic No

2 42/M 1 Transcervical 1 Tonsillar infection No
3 64/F 1 Transcervical 2 Parapharyngeal No
Right VATS 1
4 49/M 2 Transcervical and right VATS 1 Tonsillar infection Presurgical
5 54/M 1 Transcervical and left thoracotomy 1 Odontogenic No
6 26/M 2 Transcervical 2 Odontogenic Postsurgical
Transcervical and right thoracotomy 1
7 48/F 1 Peritonsillar abscess debridement 1 Parapharyngeal No
Transcervical 1
8 55/F 1 Transcervical 1 Cervical No
9 38/M 1 Transcervical and right thoracotomy 1 Parapharyngeal No
Abbreviations: DNM, descending necrotizing mediastinitis; VATS, video-assisted thoracic surgery.

Discussion observed organisms. 5,9 In patients with diabetes, Gram-

negative bacteria such as Klebsiella can also be identified.10
Descending necrotizing mediastinitis is an uncommon but life-
Broad-spectrum antibiotics that cover Gram-positive and anae-
threatening disease caused by odontogenic, pharyngeal, or cer-
robic bacteria as well as Gram-negative bacteria (in diabetic
vical infection spreading into the mediastinum through the
patients) are crucial to limit the further spread of infection.
anatomical cervical fascial planes, including the retropharyn-
Antibiotic therapy should be adjusted according to the results
geal, pretracheal, and paraesophageal planes.
of microbiological assessment. In our study, identified micro-
The most frequent cause of DNM is odontogenic infection
organisms were detected only in 3 patients, and no microorgan-
(60%-70%),4 and other causes include parapharyngeal or peri- isms could be identified in the other 6 patients. This might be
tonsillar abscess, epiglottitis, thyroiditis, trauma, and iatrogenic due to the use of antibiotics prior to culture.
injury such as tracheal rupture caused by endotracheal intuba- Antibiotic therapy alone is insufficient for the treatment of
tion.2 Risk factors for DNM include poor dentition, diabetes, DNM, which has a high mortality (55%-86%),11 and early
AIDS, and excessive alcohol consumption.5 In our study, odon- surgical intervention by ENT and cardiothoracic surgeons is
togenic infection and parapharyngeal infection were the most essential. The surgical approach is determined according to the
common origins (n ¼ 3 for both), and 3 of the 9 (33.3%) type of DNM, and there is consensus that drainage of both the
patients had diabetes. original and the mediastinum infection is necessary. In our
Clinical presentation is often mild and nonspecific, thus study, 3 patients underwent reoperations because only periton-
almost always leading to late diagnosis. Typical symptoms sillar, submandibular, or parapharyngeal abscess drainage was
related to initial cervical or odontogenic infection include performed during their primary surgery. For patients with type
fever, pain, dysphagia, neck edema, and dyspnea. However, 1 DNM, a transcervical incision with extension to the bilateral
infection can spread rapidly into the mediastinum if treatment sternocleidomastoid muscles is recommended because this can
measures are insufficient, leading to chest discomfort, respira- provide excellent exposure for judicious debridement and drai-
tory distress, sepsis, and eventually death. Early recognition, nage within the neck. The anterior mediastinum can also be
diagnosis, and treatment are associated with good prognosis. accessed using this approach.9,12 In cases of advanced disease
Computed tomography scanning is the gold standard for (type 2) with higher mortality, a more aggressive surgical
early detection and diagnosis of DNM. It can assess the extent approach via thoracotomy (especially for type 2B) combined
of infection, establish the diagnosis, and aid with surgical treat- with transcervical debridement is recommended.9,11 Right pos-
ment.6-8 The type of DNM can also be classified according to terolateral thoracotomy provides better access compared to the
CT scanning, as mentioned before. However, 2 patients in our left thoracotomy, and it is well tolerated in most patients and
study showed infections within both lower anterior mediasti- can afford excellent access to the thoracic cavity. However, left
num (type 2A) and posterior mediastinum (type 2B). So, we thoracotomy is also reliable if the left side is severely affected.
think it may be more suitable to subdivide type II into type 2A, In some cases of superior mediastinitis (type 2A), a subxiphoid
2B, and 2C. A postoperative control CT scan of the neck and incision is also reliable.13,14 Drainage of the superior medias-
thorax at 48 to 72 hours or in the case of clinical deterioration is tinum by sternotomy has also been reported, but this is unfa-
recommended to determine the necessity of reoperation. vorable due to the high risk of osteomyelitis.
Descending necrotizing mediastinitis is mainly a mixed Some reports also recommend the use of VATS, which has
anaerobic and aerobic polymicrobial infection, and Streptococ- shown similar results to open approaches and can also be used
cus anginosus, Staphylococcus aureus, Prevotella, and in children.10,11,14 However, this allows only narrow access to
Fusobacterium necrophorum are among the most commonly the mediastinum, limiting the ability of the surgeon to excise all
Wu et al 353

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