A 64-year-old man who presents with a sore throat and fever has an abscess in the right tonsillar fossa which is drained. One week later, while still on antibiotics, he becomes septic and the chest x-ray and CT scan shown are obtained. The best treatment is

A. anterior cervical mediastinotomy.
B. cervical incision and mediastinoscopy for drainage.
C. median sternotomy for drainage.
D. right thoracotomy for drainage.
E. subxiphoid drainage.

Answer D

Acute descending necrotizing mediastinitis is a lethal infection that can complicate purulent infections of the oropharynx. Primary sites of infection include tonsillar abscesses, retropharyngeal abscesses, and odontogenic infections. Pathogens usually are mixed aerobic and anaerobic organisms, although aerobic beta-hemolytic streptococcus is the only organism reliably cultured. Antibiotics to control both aerobic and anaerobic infections should be instituted, but drainage of the purulent collections is critical.

These virulent infections track into the mediastinum via the pretracheal space, carotid sheath, the retropharyngeal space, or the paraesophageal space. Despite antibiotic therapy and drainage of the deep cervical space via an anterior cervical mediastinotomy, the infection can progress to involve the mediastinum. Anterior cervical mediastinotomy is appropriate if the process has not extended below the level of the fourth thoracic vertebra. Mediastinoscopy does not play a role. If the process extends below T4 (best judged by a CT scan), cervical drainage should be accompanied by more radical debridement and drainage. This is best via thoracotomy and drainage of the mediastinum. Empyema with loculated pleural collections are also drained adequately by this approach. Anterior collections to the left of the midline can also be reached. When the infection is confined to the anterior mediastinum, subxiphoid drainage is performed on occasion. A median sternotomy, while providing wide exposure of the anterior mediastinum, should not be done since a purulent sternal wound infection may result.

Estrera AS, Landay MJ, Grisham JM, et al. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-52.
From January 1975 through July 1981, ten patients with mediastinitis complicating an oropharyngeal infection, that is, a form of mediastinitis best termed as DNM, were encountered at our institution. Based upon rather relatively stringent diagnostic criteria, 21 other instances were found in the literature from 1960 to 1980, a time period well into the antibiotic era. The predominant underlying oropharyngeal infection was of odontogenic origin, specifically, infection involving the manibular molars. Bacteriologically, DNM is most frequently a polymicrobial process, with anaerobes playing a major role. Although there has been a decline in the over-all incidence of DNM since the introduction of antibiotics, its morbid and lethal nature persists, as evidenced by the present prohibitive mortality of approximately 42 per cent. Delayed diagnosis and inadequate drainage procedures are the primary underlying factors contributing to this high mortality. At present, CT scan is the single most important tool for the early diagnosis of DNM. This noninvasive procedure also helps determine the adequacy of the surgical drainage procedure performed. However, with all the presently available diagnostic tools, it is still the high index of suspicion by physicians toward patients with unrelenting oropharyngeal or deep neck infection that is of utmost importance for making an early diagnosis of DNM. In view of our experience and that of others, we believe that only through aggressive combined medical and surgical management can the highly morbid, if not lethal, course of DNM be reversed. It should be emphasized that, to accomplish successful operative intervention, a thorough knowledge of the complex anatomy of the region is crucial.

Wheatley MJ, Sterling MC, Kirsch M, et al. Descending necrotizing mediastinitis-transcervical drainage is not enough. Ann Thorac Surg 1990;49:780-84.
One of the most lethal forms of mediastinitis is descending necrotizing mediastinitis, in which infection arising from the oropharynx spreads to the mediastinum. Two recently treated patients are reported, and the English-language literature on this disease is reviewed from 1960 to the present. Despite the development of computed tomographic scanning to aid in the early diagnosis of mediastinitis, the mortality for descending necrotizing mediastinitis has not changed over the past 30 years, in large part because of continued dependence on transcervical mediastinal drainage. Although transcervical drainage is usually effective in the treatment of acute mediastinitis due to a cervical esophageal perforation, this approach in the patient with descending necrotizing mediastinitis fails to provide adequate drainage and predisposes to sepsis and a poor outcome. In addition to cervical drainage, aggressive, early mediastinal exploration--debridement and drainage through a subxiphoid incision or thoracotomy--is advocated to salvage the patient with descending necrotizing mediastinitis.