Clinical features and outcome of patients with descending necrotizing mediastinitis: prospective analysis of 34 cases

Abstract

Purpose: We aimed to investigate clinical features of patients with descending necrotizing mediastinitis (DNM) in order to improve management and outcome. Methods: We prospectively examined all patients with DNM admitted to the Intensive Care Unit (ICU) during the period from April 2007 to December 2013. Demographics, clinical features, microbiology, medical and surgical treatment data were recorded. Survivor and nonsurvivor groups were analyzed to identify factors associated with mortality. Results: Overall, 34 patients with DNM have been included. The mean age was 46.8 ± 11.2 years (range 24–70). The male/female ratio was 3.25. DNM arose from odontogenic infection in 22 (65 %) patients; from peritonsillar abscess in 9 (26 %) patients and from paranasal sinus in 3 (9 %) patients. Microbiological cultures revealed a high percentage of aerobic/anaerobic coinfection. Nonsurvivors were statistically more likely to have higher SAPS II score (mean difference 19.1, 95 % CI 12.3–25.9 P < 0.01) and more severe disease (P < 0.01) than survivors. Positive correlation was found between time to ICU admission after head or neck infection diagnosis and SAPS II score (ρ = 0.5, P = 0.03). The same was true for ICU length of stay and time to ICU admission (ρ = 0.6, P < 0.01) and time to surgery (ρ = 0.5, P = 0.03). Surgical treatments consisted in: transcervical drainage in 14 cases, (42 %); irrigation through subxiphoid and cervical incisions of the anterior mediastinum with additional percutaneous thoracic drainage when necessary in ten cases, (29 %); thoracotomy with radical mediastinal surgical debridement, excision of necrotic tissue and decortication in ten cases, (29 %). We have found a mortality rate of 12 %. Patients with DNM type IIB were admitted to the ICU later than patients with DNM type I and type IIA (mean difference 3.2 days, 95 % CI 1.2–5.1, P 0.02). Conclusions: Prompt ICU admission in order to manage severe sepsis and/or septic shock, along with early and aggressive surgery and adequate antimicrobial therapy, could be key factors in reducing DNM mortality.