Management of a difficult infectional disease: Descending necrotizing mediastinitis.

Introduction: Descending Necrotizing Mediastinitis (DNM) is the fatal form of mediastinitis and mostly develops as a complication of peritonsillar abscesses or dental-odontogenic infections. The aim of this study is to evaluate clinical and surgical feature of the patients with DNM who were managed in our clinic.

Methodology: We retrospectively evaluated 13 consecutive patients with the diagnosis of DNM between February 2005 and February 2018. All of them had the typical physical appearance, history and radiological findings.

Results: Ten (77%) patients were male, 3 (23%) patients were female with a median age of 48.2 (18-76 years). All patients underwent Cervico-Mediastinal Drainage (CMD) with debridement of the necrotic and infected tissues. Other supplimantary surgical procedures were tube thoracostomy (n = 8), VATS mediastinal drainage (n = 4), tracheostomy (n = 2) and thoracatomy (n = 1). The median time to diagnosis of DNM, tube drainage (inserted after CMD) removal time, tube thoracostomy removal time, lenght of hospital stay were 1.8 (range 1-4) days, 13.6 (range 10-20), 12.6 days (range 10-27) and 21.5 days (range 15-30), respectively. Appropriate and potent antibiotics were used according to the fever-CRP response with the consultation on infectious disease specialist. Two patients were lost due to fulminant sepsis (n = 1) and massive cervical haemorrhage (n = 1). Overall mortality rate was 15%. Complications were recorded in 6 patients (46%).

Conclusions: The critical point in the management of DNM is the correct diagnosis, rapid surgical intervention with antibiotherapy and close follow-up for possible complications. We concluded that the combination of minimally invasive management as VATS-tube thoracostomy with CMD is the most appropriate surgical interventions.