Management of Descending Necrotizing Mediastinitis, a Severe Complication of Deep Neck Infection, Based on Multidisciplinary Approaches and Departmental Co-Ordination

Objectives Descending necrotizing mediastinitis (DNM) developing after deep neck infection (DNI) is a potentially lethal disease of the mediastinum with a mortality rate as high as 40% prior to the 1990s. No standard treatment protocol is available. Here, we present the outcomes of our multidisciplinary approaches for treating DNM originating from a DNI. Methods Between June 2016 and July 2021, there were 390 patients with DNIs admitting to our tertiary hospital. A total 21 patients with DNIs complicated with DNM were enrolled. The multidisciplinary approaches included establishment of airway security, appropriate surgery and antibiotics, extracorporeal membrane oxygenation, and intensive care unit management. The clinical variables were analyzed. Results Two patients died and 19 survived (mortality 9.5%). The patients who died had a higher mean C-reactive protein (CRP) level than did those who survived (420.0 ± 110.3 vs 221.8 ± 100.6 mg/L) (P = .038). The most common pathogens were Streptococcus constellatus and Streptococcus anginosus. From 2001 to 2021, the average mortality rate of studies enrolling more than 10 patients was 16.1%. Conclusion Multidisciplinary approaches, early comprehensive medical treatment, and co-ordination among departments significantly reduce mortality. Patients with severe inflammation and high CRP levels require intensive and aggressive interventions.

A Case of Descending Necrotizing Mediastinitis in a Previously Healthy Child

Descending necrotizing mediastinitis (DNM) is a rare complication of oropharyngeal and cervical infection, especially in children. We report a case of DNM secondary to a cervical abscess in a previously healthy 1-year-old boy. The patient presented with redness and swelling of the neck and fever. He was treated with an antimicrobial agent for the diagnosis of cervical lymphadenitis. On the sixth day, a huge mediastinal abscess was found, and he was admitted to the intensive care unit. He was successfully treated with surgical drainage and appropriate antimicrobial therapy. The pus culture isolated multiple bacteria, including methicillin-resistant Staphylococcus aureus (MRSA). Although we did not use an antimicrobial agent covering MRSA, the symptoms and test results improved. Washing with drainage was effective. The patient required multidisciplinary treatment, and we collaborated with specialists in other departments. DNM is a severe disease in which team medical care is needed to provide appropriate treatment.

Detection of aerobe–anaerobe mixed infection by metagenomic next-generation sequencing in an adult suffering from descending necrotizing mediastinitis

Background Descending necrotizing mediastinitis (DNM) is one of the most virulent forms of mediastinitis. The main causes of high mortality in DNM are believed to stem from difficulty and delay in the diagnosis. Fast and accurate identification of pathogens is important for the treatment of these patients. Metagenomics next-generation sequencing (mNGS) is a powerful tool to identify all kinds of pathogens, especially for rare and complex infections. Case presentation A 64-year-old male patient was admitted to the intensive care unit (ICU) with unconsciousness, dyspnea, and swelling in the mandible and neck. Computed tomography (CT) scan results combined with clinical laboratory examination indicated DNM. Vancomycin and imipenem were used, and vacuum sealing drainage was applied for debridement and drainage of the infected area. The positive mNGS results of drainage fluid confirmed the presence of mixed infection caused by Streptococcus anginosus, Prevotella oris, and several other anaerobes. The antibiotics were adjusted to piperacillin/tazobactam and tinidazole according to the mNGS results and antimicrobial susceptibility testing of cultured pathogens. After 11 days of antibiotic therapy, the infection symptoms of the neck and mediastinum improved, and the patient was transferred out of the ICU on the 26th day after negative result of drainage fluid culture. Conclusion This case suggested that mNGS is a promising technology for precise and fast pathogens identification with high sensitivity, which may guide the diagnosis of infectious diseases in the future trend.