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Infectious mediastinitis — Clinical Guidelines

Overview

Descending necrotizing mediastinitis (DNM) is a severe, potentially fatal complication arising from infections in the oropharynx or upper respiratory tract, characterized by the spread of infection into the mediastinum 1 3 5 15.

Diagnosis

Clinical Presentation: Severe chest pain, fever, dyspnea, and signs of sepsis 1 3 15.

Imaging: Computed tomography (CT) of the neck and chest essential for identifying collections and spread 1 4 7 10 15.

Laboratory Tests: Elevated inflammatory markers (CRP, ESR) 1 3 15.

Diagnostic Criteria: Confirmed by imaging showing mediastinal involvement secondary to cervical infection 2 7 10.

Management

First-Line Treatment: Intravenous broad-spectrum antibiotics targeting common pathogens (e.g., Streptococcus, anaerobes) 1 3 15.

Surgical Intervention:

- Aggressive Drainage: Early surgical drainage via transcervical mediastinotomy or thoracotomy for both anterior and posterior collections 3 4 7 10 12 13. - Conservative Management: Considered in selected cases with image-guided percutaneous drainage 1 9.

Adjunctive Therapies:

- Interventional Radiology: For less invasive drainage techniques 9. - Intensive Care Support: Monitoring and management in an ICU setting 1 11.

Special Populations

Elderly: Higher risk of complications; aggressive surgical intervention may be necessary 3 8.

Comorbidities: Presence of comorbidities can influence treatment complexity and outcomes 8 13.

Key Recommendations

Early Imaging and Surgical Drainage: Prompt CT imaging followed by surgical drainage (transcervical or thoracotomy) for confirmed DNM to improve survival 3 4 7 10 12 13 (Evidence: Strong).

Antibiotic Therapy: Initiate broad-spectrum intravenous antibiotics targeting common pathogens associated with DNM 1 3 15 (Evidence: Strong).

Consider Interventional Radiology: For less invasive drainage in selected cases where surgical intervention is high-risk 9 (Evidence: Moderate).

Intensive Care Monitoring: Manage patients in an ICU setting to address hemodynamic instability and sepsis 1 11 (Evidence: Moderate).

Aggressive Approach in High-Risk Groups: Elderly patients and those with comorbidities require particularly aggressive management due to higher mortality risk 8 13 (Evidence: Moderate).

References

1 Iyer S, Collum J, Babores M. Descending necrotizing mediastinitis: a conservative approach. Ear, nose, & throat journal 2014. link 2 Ishinaga H, Otsu K, Sakaida H, Miyamura T, Nakamura S, Kitano M et al.. Descending necrotizing mediastinitis from deep neck infection. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2013. link 3 Iyer AP, Kugathasan G, Prabha R, Malik P, Kuteyi O, Larbalestier R. Descending mediastinitis managed by sternotomy, taurolidine and delayed closure. Asian cardiovascular & thoracic annals 2013. link 4 Vural FS, Girdwood RW, Patel AR, Zigiriadis E. Descending mediastinitis. Asian cardiovascular & thoracic annals 2012. link 5 Cho JS, Kim YD, I H, Lee SK, Jeong YJ. Treatment of mediastinitis using video-assisted thoracoscopic surgery. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2008. link 6 De Freitas RP, Fahy CP, Brooker DS, Primrose WJ, McManus KG, McGuigan JA et al.. Descending necrotising mediastinitis: a safe treatment algorithm. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2007. link 7 Misthos P, Katsaragakis S, Kakaris S, Theodorou D, Skottis I. Descending necrotizing anterior mediastinitis: analysis of survival and surgical treatment modalities. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2007. link 8 Roccia F, Pecorari GC, Oliaro A, Passet E, Rossi P, Nadalin J et al.. Ten years of descending necrotizing mediastinitis: management of 23 cases. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2007. link 9 Ho MW, Dhariwal DK, Chandrasekhar J, Patton DW, Silvester KC, Sadiq S et al.. Use of interventional radiology in the management of mediastinitis of odontogenic origin. The British journal of oral & maxillofacial surgery 2006. link 10 Mihos P, Potaris K, Gakidis I, Papadakis D, Rallis G. Management of descending necrotizing mediastinitis. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2004. link 11 Makeieff M, Gresillon N, Berthet JP, Garrel R, Crampette L, Marty-Ane C et al.. Management of descending necrotizing mediastinitis. The Laryngoscope 2004. link 12 Endo S, Murayama F, Hasegawa T, Yamamoto S, Yamaguchi T, Sohara Y et al.. Guideline of surgical management based on diffusion of descending necrotizing mediastinitis. The Japanese journal of thoracic and cardiovascular surgery : official publication of the Japanese Association for Thoracic Surgery = Nihon Kyobu Geka Gakkai zasshi 1999. link 13 Sancho LM, Minamoto H, Fernandez A, Sennes LU, Jatene FB. Descending necrotizing mediastinitis: a retrospective surgical experience. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 1999. link00168-2) 14 Berlot G, Tomasini A, Cioffi V, Illicher C, Semeraro A. Fatal Streptococcus viridans descending mediastinitis: case report and review of the literature. European journal of emergency medicine : official journal of the European Society for Emergency Medicine 1997. link 15 Alsoub H, Chacko KC. Descending necrotising mediastinitis. Postgraduate medical journal 1995. link 16 Musgrove BT, Malden NJ. Mediastinitis and pericarditis caused by dental infection. The British journal of oral & maxillofacial surgery 1989. link90084-3)

Infectious mediastinitis