Optimal Surgical Management of Descending Necrotising Mediastinitis: Our Experience and Review of Literature

IntroductionDescending necrotising mediastinitis is a form of mediastinitis caused by odontogenic infection or deep cervical infections, which spreads to the mediastinum via the cervical fascial planes. Despite the increased use of CT scan as a diagnostic aid and the improvement in antibiotics, mortality in patients with descending necrotising mediastinitis remains high, reported between 25 and 40% in the literature. Surgical management and optimal form of mediastinal drainage remain controversial.Patients and methodsWe have treated three patients with descending necrotising mediastinitis at our institution. Two patients were male and one was female with mean age 54.3 ± 12.5 years. One of the patients was a known diabetic. The primary oropharyngeal infection was Ludwig's angina, odontogenic abscess and parapharyngeal abscess. All patients underwent mediastinal drainage, one through midsternotomy and two through right thoracotomy in addition to cervical drainage. All the three patients had mixed aerobic and anaerobic infection.ResultsThere was no perioperative mortality. Mean ICU stay was 32 days (12–53 days). All three patients had septicaemic shock requiring prolonged inotropic support. Two patients required tracheostomy because of prolonged ventilation. All the patients had recurrent abscesses and collections either in neck or in chest requiring drainage either surgically or percutaneously under CT scan or ultrasound guidance, thus decreasing the need of repeated surgical procedures.ConclusionDescending necrotising mediastinitis is a potentially fatal condition. Early diagnosis, prompt surgical drainage, monitoring of disease process, appropriate medical management in an intensive care unit and a multi-disciplinary approach can significantly reduces the mortality in this otherwise fatal condition. Percutaneous drainage of recurrent abscesses and collections can decrease the need of repeated surgical procedures in these critically ill patients.