Descending Necrotizing Mediastinitis: Review of the Literature and Controversies in Management

Any deep cervical infection has to be aggressively treated and CT scan of the chest should be performed to exclude the possibility of downward spread of the infection within the mediastinum. Early recognition of DNM is problematic because of its rarity and the non-specific symptoms in its early phase. DNM can rapidly progress to involve the entire mediastinum. Aggressive surgery upon diagnosis has to be performed, usually through a combination of cervicomediastinal and thoracic approach. Cervicomediastinal drainage alone for DNM not extending below the carina level or combined with subxiphoid drainage or anterior mediastinotomies is associated with higher mortality rates. Thoracotomy on the most involved side or bilateral thoracotomies give the best exposure for adequate mediastinal drainage. Median sternotomy or VATS procedures can be performed if one-lung ventilation can be tolerated by the patient. Pleural and pericardial cavities and all mediastinal spaces should be properly drained. Repeat CT scan of the neck and chest should be performed in all patients 48-72 hours after drainage of the infection or even earlier in case of further deterioration of the patient or persistent sepsis. Mortality rate in recent series ranges between 10% and 30%. The development of purulent pericarditis and/or failure of more than two organs before mediastinal drainage are associated with higher risk of fatal outcome. Prolonged ICU and hospital stays are the rule, while re-intervention rate for persistent sepsis exceeds 30%. The re-intervention rate is higher after mediastinal drainage performed through approaches which offer limited exposure to the whole mediastinum.