Descending necrotizing mediastinitis: An analysis of the effects of serial surgical debridement on patient mortality

Objectives: Descending necrotizing mediastinitis is a polymicrobial infection originating in the oropharynx with previously reported mortality rates of 25% to 40%. This investigation reviews the effects of serial surgical drainage and debridement on the survival of patients with descending necrotizing mediastinitis. Methods: A retrospective review of patients from 1980 through 1998 with a diagnosis of descending necrotizing mediastinitis was performed. Their records were abstracted for personal demographics, hospital course, morbidity, and mortality. Also abstracted were all reports of patients with descending necrotizing mediastinitis published in English between 1970 and 1999. Results: We treated 10 patients in whom descending necrotizing mediastinitis was identified. The mean age of the patients was 38 years. They underwent a mean of 6 ± 4 computed tomographic imaging studies, 4 ± 1 transcervical drainage procedures, and 2 ± 1 transthoracic drainage procedures. Three patients required abdominal exploration and 4 underwent tracheostomy. No deaths occurred. In contrast, 96 patients with descending necrotizing mediastinitis were identified from the literature with a mean age of 38 years. They underwent a mean of 2 ± 1 computed tomographic imaging studies, 2 ± 1 transcervical drainage procedures, and 0.7 + 0.3 transthoracic drainage procedures. Sixteen (17%) patients required abdominal exploration and 34 (35%) underwent tracheostomy. Twenty-eight (29%) patients from the literature cohort died during their treatment. Conclusion: Descending necrotizing mediastinitis remains a life-threatening infection. On the basis of experience accrued in treating these patients, an algorithm incorporating computed tomographic imaging for diagnosis and surveillance and serial transcervical and transthoracic operative drainage is outlined in the hope of reducing the excessive mortality of descending necrotizing mediastinitis. (J Thorac Cardiovasc Surg 2000;119:260-7)