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LETTER TO THE EDITOR
Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 219-220

Extensive descending necrotizing mediastinitis can be managed conservatively


1 Department of Medicine, Dr. Rajendra Prasad Government Medical College Tanda, India
2 Department of Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Web Publication10-Sep-2015

Correspondence Address:
Vivek Chauhan
Assistant Professor, Medicine, Dr. Rajendra Prasad Government Medical College Kangra, Tanda, Kangra-176 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5151.165018

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How to cite this article:
Chauhan V, Thakur S. Extensive descending necrotizing mediastinitis can be managed conservatively. Int J Crit Illn Inj Sci 2015;5:219-20

How to cite this URL:
Chauhan V, Thakur S. Extensive descending necrotizing mediastinitis can be managed conservatively. Int J Crit Illn Inj Sci [serial online] 2015 [cited 2018 May 25];5:219-20. Available from: http://www.ijciis.org/text.asp?2015/5/3/219/165018

Dear Editor,

In descending necrotizing mediastinitis (DNM), mortality rate is high, that is, 19-47% even with surgery and intensive care. [1] However, we were able to treat extensive DNM conservatively with antibiotics and chest tube drainage alone without any surgical procedure in a 40-year-old male who presented in the emergency department with chest pain, hoarseness, odynophagia, dyspnea, and cough. It started 7 days back with sore throat with fever. Examination revealed a swelling in the posterior pharyngeal wall and on right side of the neck. He had vocal cord palsy on right side. The computed tomography (CT) chest showed air and fluid pockets in the mediastinum and right pleural cavity [Figure 1]. The patient was put on chest tube drainage and intravenous (IV) antibiotics (ceftriaxone, metronidazole, and aminoglycoside). Before the decision for surgery was finalized, the patient felt improvement symptomatically; and thus refused to give consent for surgery. He showed continuous improvement on conservative management and got discharged after a month. Around 1,600 ml of pus in total was drained.
Figure 1: CT chest showing widened mediastinum and air within mediastinum (vertical arrows) and pyopneumothorax on right side (horizontal arrows). CT = Computed tomography

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Descending mediastinitis is a dreaded condition and in the presence of comorbid conditions like diabetes, immunocompromized state, hereditary or acquired, or chronic illness; mortality rate is as high as 67%. [2] For reasons unknown, it has a male preponderance with male to female ratio of 6:1. [2] Hamman's sign (systolic crunch over the precordium) may be present. In complicated cases; evidence of sepsis, pleural effusion, empyema, pericarditis, and cranial nerve palsy may be found. Diagnosis is based on Estretra et al.'s, [1] criteria:

(i) Severe oropharyngeal infection, (ii) X-ray features of mediastinitis, (iii) necrotizing mediastinal infection at operation or at postmortem, and (iv) relationship between the DNM and the oropharyngeal infection.

Most cases of DNM are limited to the upper mediastinum and can be adequately drained by a transcervical approach. Formal thoracotomy should be reserved for cases extending below the plane of the tracheal bifurcation. [3] The key to conservative management in our patient was natural drainage of mediastinum. Chest tube drainage alone is not recommended, but it can be tried along with intensive care in situations where either patient refuses for surgery or the surgical expertise is not immediately available.

 
   References Top

1.
Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-2.  Back to cited text no. 1
    
2.
Mediastinitis in Emergency Medicine. 2013 Feb 27 [cited 2014 Sep 22]; Available from: http://emedicine.medscape.com/article/784277-overview.  Back to cited text no. 2
    
3.
Ridder GJ, Maier W, Kinzer S, Teszler CB, Boedeker CC, Pfeiffer J. Descending necrotizing mediastinitis: Contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg 2010;251:528-34.  Back to cited text no. 3
    


    Figures

  [Figure 1]


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