Descending necrotizing mediastinitis

Last revised by Dr Daniel J Bell on 26 Feb 2018

Descending necrotizing mediastinitis is a severe form of mediastinitis and refers to an acute, polymicrobial infection of the mediastinum that usually spreads downwards from oropharyngeal, cervical, and odontogenic infection.

  • diabetes: more than one-third of patients were noted as having diabetes in one study 9

Continuity of the fascial planes between the neck and mediastinum may allow infection to spread from the oral cavity and neck into the mediastinum. Three potential pathways for the spread of infection may exist from the neck to the mediastinum

  • retropharyngeal-retrovisceral route to the posterior mediastinum (considered most common)
  • pretracheal route to the anterior mediastinum
  • lateral pharyngeal route to the middle mediastinum

Commonly reported aerobic bacteria include 9

  • Streptococcus spp. (S. constellatusS. intermediusS. agalactiaeS. mitis).

Commonly reported anaerobic bacteria include 9

  • peptostreptococcus, Bacteroides fragilis, Prevotella, and fusobacterium

Neck radiography may show subcutaneous emphysema, prevertebral soft-tissue swelling, mediastinal gas, and/or superior mediastinal widening.

CT chest may show mediastinal gas +/- fluid collections. Accompanying CT neck findings include thickening of the subcutaneous tissues in the neck, thickening or enhancement of cervical fascia and muscles, fluid collections, and enlarged lymph nodes.

A CT classification system has been proposed by Endo et al. to define the extent of disease and aid patient management.

  • type 1: localized above the carina
  • type 2: below carina
    • type 2a: extends to the lower anterior mediastinum
    • type 2b: extends to the anterior and posterior mediastinum

It can carry high morbidity and mortality with reported mortality rates ranging from 30-50%.

Patients with type 1 disease may not always require aggressive mediastinal drainage. Those with type 2b disease are advised to undergo complete mediastinal drainage and débridement via thoracotomy, while those with type 2a disease may benefit from subxiphoid mediastinal drainage without sternotomy 2,4.

It was first reported by Pearse in 1938. 

ADVERTISEMENT: Supporters see fewer/no ads

Cases and figures

  • Case 1
    Drag here to reorder.