Acute Necrotizing Mediastinitis

James E. Speicher, Mark D. Iannettoni

Key Points

Acute necrotizing mediastinitis is a destructive, life-threatening condition akin to necrotizing fasciitis and acute necrotizing pancreatitis. Most commonly arising from an oropharyngeal source, the infection is a polymicrobial mix of aerobes and anaerobes that act synergistically. Diagnostic delay and inadequate surgical drainage lead to inordinate mortality. The cornerstones of diagnosis and treatment include immediate administration of broad-spectrum antibiotics, early contrast-enhanced cervicothoracic CT scanning, and aggressive surgical therapy aimed at both the neck and mediastinum. Best results are achieved by a multidisciplinary approach including thoracic surgeons, otolaryngologists, and, with odontogenic infection, oral maxillofacial surgeons. Unless mediastinal involvement is minimal and located above the carina, a thoracic approach must supplement the cervical approach, and serial operations may be required. Tracheostomy is often necessary but should be used selectively. The use of minimally invasive drainage procedures have become more common in recent years and recent case series have demonstrated minimally invasive approaches to be safe and effective.

Acute necrotizing mediastinitis (ANM), also known as descending necrotizing mediastinitis, is a life-threatening condition. Without timely diagnosis and aggressive surgical management, fatal outcome is likely. Surgical mortality exceeded 50% in the preantibiotic era,[1] but even after availability of broad-spectrum antibiotics, mortality still approached 40%.[2] Introduction of contrast medium-enhanced cervicothoracic computed tomography (CT) led to improved outcomes by facilitating diagnosis and directing operative therapy. Mortality reported in case series of two or more patients published from 1990 to present has decreased markedly (Table 1). Most recent reports attribute successful management of ANM to earlier diagnosis via improved imaging techniques, immediate institution of appropriate antibiotics, and prompt aggressive surgery with mandatory cervical and/or transthoracic drainage. However, debate remains as to whether transthoracic surgical intervention, as well as tracheostomy, should be compulsory.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]

Table 1: Acute Necrotizing Mediastinitis Case Series: 1990-2016
				Surgical Treatment
Author (Year)	Mean Age	No.	M : F	Cervicotomy	Thoracotomy/Thoracoscopy	Tracheostomy	Survival (%)
Wheatley et al[12] (1990)	33	2	2 : 0	2	2	2	100%
Marty-Ane et al[8] (1994)	49	6	6 : 0	6	6	NA^†	83%
Brunelli et al[3] (1996)	44	5	5 : 0	5	2	2	100%
Ris et al[11] (1996)	35	3	1 : 2	3	3	0	67%
Casanova et al[13] (1996)	< 35*	2	2 : 0	2	2	0	100%
Corsten et al[5] (1997)	46	8	5 : 3	8	6	1	88%
Kiernan et al[7] (1998)	56	5	2 : 3	5	1	4	100%
Marty-Ane et al[9] (1999)	42	12	11 : 1	12	11	NA^†	83%
Freeman et al[6] (2000)	38	10	9 : 1	10	10	4	100%
Papalia et al[14] (2001)	39	13	9 : 4	13	11	4	77%
Mihos et al[10] (2004)	55	6	2 : 4	6	6	1	83%
Makeieff et al[15] (2004)	42	17	16 : 1	17	14	0	82%
Son et al[16] (2006)	51	9	6 :3	9	9	2	89%
Cho et al[17] (2008)	52	17	8 :9	13	15	0	80%
Ridder et al[18] (2010)	52	45	33 :12	44	7	28	89%
Karkas et al[19] (2010)	54	17	12 :5	17	7	15	94%
Kocher et al[20] (2012)	48	17	8 :9	11	16	9	94%
D’Cunha et al[21](2013)	33	8	5 :3	6	6	0	100%
Dajer-Fadel et al[22](2014)	41	60	43 :17	49	60	47	65%
Taylor et al[23] (2014)	36	6	3:3	5	6	NA^†	100%
Wu et al[24] (2021)	44	9	6:3	9	6	2	100%
Vodicka et al[25] (2022)	56	80	53:27	53	48	NA^†	88%
Cumulative	48*	357	247:110	305	254	121^†	84%
Age of one “young” patient was not included in the manuscript. ^†Values were not included in the respective publications.* M : F, male : female ratio.

ANM generally results from odontogenic, peritonsillar, or other pharyngeal infections.[3],[5],[6],[7],[8],[10],[12] It may also result from iatrogenic oropharyngeal perforation, thoracic esophageal perforation, paraesophageal hernia with intrathoracic gastric perforation, cervical trauma, epiglottitis, parotitis, sinusitis, fungal infections, histoplasmosis, sternoclavicular joint infection, extension of retroperitoneal pancreatic infection into the chest, iatrogenic infusion into the mediastinum via improperly placed central venous line, and illicit intravenous drug administration.[3],[12],[15] Cervical esophageal perforation, iatrogenic or otherwise, is thought to represent a distinct condition with a less virulent course.[12] Although neck exploration with cervical drainage and operative esophageal repair may be required, progression of disease into the mediastinum, with necrosis, is unusual. Also, ANM must not be confused with generally less threatening mediastinal infections, such as primary abscess, which lack the descending, necrotizing process in which oral flora have become pathogenic. In comparing reports on efficacy of surgical procedures for ANM, it is imperative to verify that patients meet the criteria outlined by Estrera and colleagues in their 1983 report (Table 2).[2]

Table 2: Estrera and Colleagues’ Criteria for Acute Necrotizing Mediastinitis
1. Clinical manifestations of severe oropharyngeal infection 2. Demonstration of characteristic roentgenographics features of mediastinitis 3. Documentation of the necrotizing mediastinal infection at operation or postmortem examination or both 4. Establishment of the relationship of oropharyngeal infection with the development of the necrotizing mediastinal process
Data from Estrera AS, Landay MJ, Grisham JM, et al[2]: Descending necrotizing mediastinitis. Surg Gynecol Obstet 157:545-552, 1983.

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