Descending necrotizing mediastinitis is a rare life- threatening complication of odontogenic or oropharyngeal infection spreading into the mediastinum through the cervical fasciae. Despite improvements in diagnostic imaging and treatment, its mortality rate remains relatively high. We describe a unique case of descending necrotizing mediastinitis leading to the formation of a fistula in the lateral wall of the hypopharynx. The fistula, providing spontaneous drainage of the purulent mediastinitis, contributed to the successful outcome of the patient requiring only transcervical surgical drainage

FALCONE M

FUSCONI M

P. PALANGE

PAVONI G

POMPEO ME

SOLDO P

VENDITTI M

FALCONE, MARCO

FUSCONI, Massimo

SOLDO, Pietro

PALANGE, Paolo

VENDITTI, Mario

Archivio della ricerca- Università di Roma La Sapienza

Successful Conservative Treatment of DescendingNecrotizing Mediastinitis With Fistula Formationin the HypopharynxMarco Falcone,* Maria Elena Pompeo,* Gian Luca Pavoni,* Massimo Fusconi,yPietro Soldo,y Paolo Palange,* and Mario Venditti*Abstract: Descending necrotizing mediastinitis is a rare life-threatening complication of odontogenic or oropharyngeal infectionspreading into the mediastinum through the cervical fasciae. Despiteimprovements in diagnostic imaging and treatment, its mortality rateremains relatively high. We describe a unique case of descendingnecrotizing mediastinitis leading to the formation of a f istula in thelateral wall of the hypopharynx. The fistula, providing spontaneousdrainage of the purulent mediastinitis, contributed to the successfuloutcome of the patient requiring only transcervical surgical drainage.(Infect Dis Clin Pract 2005;13:36–38)Acute mediastinitis is a severe infection usually caused bythe esophageal rupture, spontaneous or after sternotomy.Occasionally, acute mediastinitis occurs as the complicationof an odontogenic or oropharyngeal infection which spreads tothe mediastinum through the cervical fasciae. This rare formof mediastinitis, described as descending necrotizing media-stinitis (DNM), is a life-threatening disease with a reportedmortality up to 50%.1,2 Optimal treatment of DNM is object ofdebate. Some authors recommend an aggressive approachwith extended mediastinal drainage including thoracotomy3;others recommend thoracotomy only if the infection spreadsbelow the carina anteriorly or the fourth thoracic vertebraposteriorly, whereas conservative transcervical drainageseems to be adequate in the remaining cases.1,4We describe a unique case of DNM leading to theformation of a fistula in the lateral wall of hypopharynxproviding spontaneous drainage of the purulent mediastinitis.The drainage through the fistula contributed to the successfuloutcome of the patient requiring only minimal surgicalmanagement.CASE REPORTA 69-year-old white woman, with a past history of poorlycontrolled type 2 diabetes mellitus, was admitted to our hospitalfollowing transfer from the medical ward of a peripheral hospital. Sixdays prior to admission, she had sought medical attention for a feverwhich had lasted for 7 days, associated with left mandibular pain,dyspnea, odynophagia, and neck swelling. The patient had a pasthistory of chronic periodontitis and poor hygiene of the oral cavity.She was currently receiving amoxicillin, 500 mg 3 times daily.Physical examination showed marked dehydration, body temperatureof 39.58C, heart rate 100 bpm, respiratory rate 20/min, and bloodpressure of 130/70. In addition, erythema, warmth, tenderness, andcrepitation involving the neck up to the clavicular region werepresent. Laboratory studies showed white blood cell count 14,900/mL(81% neutrophils), erythrocyte sedimentation rate (ERS) 79 mm,serum glucose 426 mg/dL, natriemia 151 mEq/L, and creatinine 3.2mg/dL. Chest x-ray did not show any significant alterations.Computed tomography (CT) scan of the neck and the upper thoraxshowed multiple abscessual areas with air collection arising from thelevel of the floor of the mouth to the paratracheal region with a spreadto the retropharyngeum space and to the posterior mediastinum notbelow the fourth thoracic vertebra (Figs. 1A and B). CT scan alsoshowed a 7-cm thyroid nodule, determining a right shift of thetrachea, and a focal lesion of consolidation in the right lower lunglobe, without pleural or pericardial effusions. Pharyngolaryngoscopyand bronchoscopy examinations revealed a 10-mm diameter necroticlesion on the lateral wall of the hypopharynx; and a biopsy wasperformed that was eventually nondiagnostic. Esophagoscopy wasnormal. Drainage of the neck abscess was performed by an incisionalong the front edge of the sternocleidomastoid muscle. Because ofthe patient’s general conditions, a more aggressive drainage bymeans of a thoracotomy was not performed. Cultures of purulentsecretions eventually yielded Streptococcus mitis and Bacteroidesspecies; empirical antibiotic treatment with piperacillin/tazobactam4.5 g 3 times daily was started. On day 2, the patient reported saltytaste and vomiting. Pharyngolaryngoscopy was performed thatshowed abundant purulent fluid collection in the hypopharynx froma large defect of the hypopharynx lateral wall. Subsequently, the36 Infectious Diseases in Clinical Practice  Volume 13, Number 1, January 2005Case Report*Department of Clinical Medicine, Divisione Clinica Medica III andyDepartment of Otolaryngology, Audiology and Phoniatry ‘‘G. Ferreri’’—Policlinico Umberto I, University of Rome ‘‘La Sapienza,’’ Italy.Address correspondence and reprint requests to Prof. Mario Venditti, Dipartimentodi Medicina Clinica, Divisione Clinica Medica III, Policlinico Umberto I,University of Rome ‘‘La Sapienza,’’ Viale Dell’Università 37—00185 Rome,Italy. E-mail: mario.venditti@uniroma1.it.Copyright n 2005 by Lippincott Williams & WilkinsISSN: 1056-9103/05/1301-0036Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.patient’s clinical conditions improved: fever and leukocytosisdisappeared and the ERS dropped to 27 mm. On day 10,superinfection with an extended spectrum b-lactamase (ESBL)producing strain of Klebsiella pneumoniae required transcervicaldrainage and debridement. Tracheostomy was performed. Thepatient definitively improved after a 3-week treatment course withimipenem 500 mg intravenously every 6 hours, and was dischargedon day 33. A 3-month follow up showed no late complications.DISCUSSIONDescending necrotizing mediastinitis refers to medias-tinal infections that begin at the oropharyngeal region andspread through deep fascial planes into the mediastinum. Inthe preantibiotic era, Pearse2 reported a mortality rate ofDNM greater than 50%. Despite improvements in diagnosticimaging and treatment, the mortality remains relatively high;in their meta-analysis, Corsten et al5 reported a fatality rateof 31% in 69 cases observed between 1970 and 1997.The deep cervical fascia is composed of 3 layers, whichdivide the neck into 3 spaces.6 The pretracheal space lies infront of the trachea and posterior to the strap muscles.Perforations of the trachea and lateral pharyngeal walls mostcommonly cause the collection of the infection in this space.Otherwise, DNM may spread along the perivascular com-partment,2 possibly producing arterial hemorrhage and cranialnerve deficits that render the infection of this space extremelydangerous. However, most of DNM2 originate from infec-tions of the second or third mandibular molars resulting insubmandibular triangle abscesses which can progress beyondthe posterior limit of the mylohyoid shelf and, ultimately,involving the retrovisceral space. In our case, the infectionspread along this plane and an odontogenic origin, althoughunproven, was highly probable. As a matter of fact, our patienthad an uncontrolled diabetes mellitus with a severe pyorrhoeaand a very poor dental hygiene.Standard treatment of DNM consists of surgicaldrainage associated with administration of antibiotics. How-ever, the optimal surgical management remains controversial,being most of the authors in favor of an aggressive surgicalapproach, including standard thoracotomy.3,5,7,8 A specialfeature of this case was the formation of a fistula in thehypopharynx, as the result of the neck infection. This fistulaformation, providing spontaneous drainage of the purulentmediastinitis, may have significantly contributed to thesuccessful outcome of the patient. Only 4 cases of DNMleading to fistula formation has been reported in the literature.Van Straalen et al9 described the case of a DNM, with a fistulaformation to the left main bronchus, after a wisdom toothextraction. More recently, Kruyt et al10 and Kato et al11reported the cases of a pleuroesophageal fistula and of atracheal fistula due to DNM that were both associated to asuccessful outcome. In the first two cases,10,11 the patientswere treated without aggressive surgery. Vice-versa in theseries of Marty-Anè et al,3 one patient with DNM and trachealfistula died on day 18 after bilateral cervicotomy, anteriormediastinotomy, and subxiphoid counterincision. Thus, webelieve that in our patient the favorable clinical evolution waslikely due to the spontaneous drainage of the septic processthat prevented massive posterior DNM spread requiringstandard thoracotomy.FIGURE 1. Massive septic process with abundant air collection in the neck region (A) with extension (arrow) in the posteriormediastinum (B).n 2005 Lippincott Williams & Wilkins 37Infectious Diseases in Clinical Practice  Volume 13, Number 1, January 2005 Treatment of Descending Necrotizing MediastinitisCopyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.Bacteriologic findings in mediastinitis, secondary toextension from head and neck sources, are mostly poly-microbic in nature with mixed aerobic and anaerobicflora.1,3,8,12 In our case, S. milleri and Bacteroides specieswere initially cultured. However, it was remarkable to observea severe superinfection with an antibiotic resistant nosoco-mially acquired pathogen as ESBL producing K. pneumoniae.In conclusion, we have described a unique case of DNMwith fistula formation in the hypopharynx leading to afavorable clinical outcome and thus requiring only minimalsurgical management. The lesson that can be learned from thiscase is that (1) as outlined by other authors,4 DNM can betreated without aggressive thoracotomy if the septic processis not extended below the fourth thoracic vertebra; (2) theformation of a fistula, providing spontaneous drainage of thepurulent mediastinitis, should not be necessarily considereda complication.REFERENCES1. Estrera AS, Landay MJ, Grisham JM, et al. Descending necrotizingmediastinitis. Surg Gynaecol Obstet. 1983;157:545–552.2. Pearse HE Jr. Mediastinitis following cervical suppuration. Ann Surg.1939;108:588–611.3. Marty-Anè CH, Berthet JP, Alric P, et al. Management of descendingnecrotizing mediastinitis: an aggressive treatment for an aggressivedisease. Ann Thorac Surg. 1999;68:212–217.4. Brunelli A, Sabbatini A, Catalini G, et al. Descending necrotizingmediastinitis. Surgical drainage and tracheostomy. Arch OtolaryngolHead Neck Surg. 1996;122:1326–1329.5. Corsten MJ, Shamji FM, Odell PF, et al. Optimal treatment of descendingnecrotizing mediastinitis. Thorax. 1997;52:702–708.6. Moncada R, Warpeha R, Pickleman J, et al. Mediastinitis fromodontogenic and deep cervical infection. Chest. 1978;73:497–500.7. Ris HB, Banic A, Furrer M, et al. Descending necrotizing mediastinitis:surgical treatment via Clamshell approach. Ann Thorac Surg. 1996;62:1650–1654.8. Wheatley MJ, Stirling MC, Kirsh MM, et al. Descending necrotizingmediastinitis: transcervical drainage is not enough. Ann Thorac Surg.1990;49:780–784.9. Van Straalen HCM, Jansveld KAF, Michels LFE, et al. Mediastinitiswith fistula formation to the left main bronchus. A complication ofwisdom tooth extraction. Chest. 1994;106:623–624.10. Kruyt PM, Boonstra A, Fockens P, et al. Descending necrotizingmediastinitis causing pleuroesophageal fistula. Successful treatmentby combined transcervical and pleural drainage. Chest. 1996;109:1404–1407.11. Kato H, Ohkubo N, Akazawa K, et al. Spontaneous closure of a largetracheal fistula due to descending necrotizing mediastinitis. Ann ThoracSurg. 2000;69:1249–1251.12. Brook I, Frazier EH. Microbiology of mediastinitis. Arch Intern Med.1996;156:333–336.38 n 2005 Lippincott Williams & WilkinsFalcone et al Infectious Diseases in Clinical Practice  Volume 13, Number 1, January 2005Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

English

Successful conservative treatment of descending necrotizing mediastinitis with fistola formation in the hypopharinx.

Archivio della Ricerca - Università di Pisa

Successful conservative treatment of descending necrotizing mediastinitis with fistola formation in the hypopharinx

Successful conservative treatment of descending necrotizing mediastinitis with fistola formation in the hypopharinx.

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