Case Study
Descending mediastinitis managed by sternotomy, taurolidine and delayed closure
Asian Cardiovascular & Thoracic Annals 21(5) 612–614 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312459045 aan.sagepub.com
Anand P Iyer, Gana Kugathasan, Ramesh Prabha, Paras Malik, Opeyemi Kuteyi and Robert Larbalestier
Abstract Descending necrotizing mediastinitis is a rare complication of upper respiratory infections. A quick diagnosis and prompt and complete surgical drainage is important for a successful outcome. A 74-year-old man with descending necrotizing mediastinitis needed a sternotomy, multiple washouts, and delayed sternal closure.
Keywords Abscess, bacterial infections, drainage, mediastinitis, taurolidine
Introduction Descending necrotizing mediastinitis (DNM) is a lifethreatening emergency after oropharyngeal infection. It is a serious infection involving the connective tissue that fills the pleural spaces and surrounds the median thoracic organs. The diagnosis must be established rapidly, and quick surgical treatment has to be given because the mortality rate could be as high as 60%.1 It usually occurs as a complication of severe cervical infection spreading along the facial planes into the mediastinum. Surgical management, particularly optimal mediastinal drainage, remains controversial with support ranging from cervical drainage alone to cervical drainage and routine thoracotomy. We describe a case in which there were pericardial abscesses requiring sternotomy, multiple washouts, and delayed sternal closure.
revealing a purulent discharge. Repeat CT showed multiple anterior and posterior mediastinal loculated collections. After sternotomy and drainage of all the abscesses, a good washout of the mediastinum and both pleural spaces was carried out with normal saline because there were empyemas on both sides. As the mediastinum was grossly infected, the sternum was not closed and Steri-Drapes were used to cover the wound. The pus grew multiple organisms both grampositive, gram-negative, and anaerobes. Broad-spectrum antibiotic treatment was initiated. The patient underwent mediastinal washout on 2 further occasions; on the last occasion, taurolidine was instilled into the mediastinum, and the sternum closed with mediastinal and pleural drains. He was extubated after few days and moved to the ward. He made a slow recovery and was eventually discharged.
Case report A 74-year-old man presented with febrile episodes and a swelling in the neck. Computed tomography (CT) showed a parapharyngeal abscess secondary to a tonsillar abscess. He underwent cervical drainage by ear, nose and throat surgeons. After admission to the intensive care unit, he did not improve, and bilateral neck exploration and washout was performed. His sepsis persisted and he had a small effusion that was drained,
Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, Australia Corresponding author: Anand P Iyer, MCh, Department of Cardiothoracic Surgery, Royal Perth Hospital, Wellington Street, Perth, WA 6000, Australia. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV CALIFORNIA SAN DIEGO on June 4, 2015
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Figure 1. Computed tomography showing multiple mediastinal abscesses and bilateral empyema.
Discussion In 1983, Estrera and colleagues2 established the following diagnostic criteria for DNM: clinical signs and symptoms of severe neck infection; typical radiologic signs including fluid and/or gas collection on chest CT; intraoperative or post-mortem documentation of mediastinal infection; and continuity between the oropharyngeal infection and the mediastinal process. The incidence of DNM is low in the current era. In the first modern series of patients with DNM published in 1938, Pearse3 reported that 49% of patients died during treatment. In spite of the introduction of intravenous antibiotics, vast improvements in anaesthesia and critical care, and the development of CT imaging, the frequency of death in patients with DNM has remained high in the antibiotic era. Recent studies have revealed a significant reduction in mortality, as reported by Marty-Ane´ and colleagues4 and Freeman and colleagues.5 This could be attributed to early diagnosis and aggressive surgical treatment. Bacteriological analysis generally reveals mixed flora. The presence of mixed aerobic/anaerobic flora in the upper aerodigestive tract, in addition to limited numbers of immune-competent cells in the cervical mediastinum, explains why the infection spreads. The patient we treated had mixed aerobic and anaerobic organisms and was treated with broad-spectrum antibiotics. Bacteria excrete substances that are instrumental in this spread. Anaerobes have an affinity for the lipid components of cell membranes, and provoke muscle cell, erythrocyte, and platelet hydrolysis. The disease process cannot be controlled without complete excision of all necrotic tissue. Due to the anatomic relationships in the cervicothoracic region and the progressive nature of DNM, several approaches to mediastinal
drainage have been proposed: transcervical, subxiphoid, median sternotomy, clamshell incision, posterolateral thoracotomy, video-assisted mediastinoscopy, and video-assisted thoracoscopic surgery. Other treatment options include drainage of the collections using thoracotomy, or video-assisted thoracoscopic drainage. Both sides can be treated at the same sitting, or one side at a time. Video-assisted thoracoscopic techniques may also be used to drain mediastinal abscesses. The advantages of video-assisted thoracoscopic surgery are that it is less invasive, allows early recovery, and an open technique can always be employed if needed later. Sternotomy is more invasive and there is a risk of sternal osteomyelitis and impaired healing of the sternum under such circumstances. In view of the multiloculated nature of the disease, we decided to approach via a sternotomy which retrospectively turned out to be beneficial because the patient needed multiple washouts in view of ongoing sepsis. During the 3rd washout, we instilled taurolidine and closed the sternum. Taurolidine, bis(1,1-dioxoperhydro-1,2,4-thiadiazinyl-4)-methane, is a drug with antimicrobial and anti-lipopolysaccharide properties. Its immunue modulatory action is reported to be mediated by priming and activation of macrophages and polymorphonuclear leukocytes.6 It is used in Royal Perth Hospital for pleural washout in cyctic fibrosis patients, after pneumonectomy, and before transplanting a donor lung. Descending mediastinitis should be recognized quickly by imaging, and aggressively treated, because any delay could result in a fatal outcome. There are various ways by which it can be treated, and delayed surgical closure with washout and taurolidine instillation should be considered as an option. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Gorlitzer M, Grabenwoeger M, Meinhart J, Swoboda H, Oczenski W, Fiegl N, et al. Descending necrotizing mediastinitis treated with rapid sternotomy followed by vacuum-assisted therapy. Ann Thorac Surg 2007; 83: 393–396. 2. Estrera AS, Landay MJ, Grisham JM, Sinn DP and Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983; 157: 545–552. 3. Pearse HE. Mediastinitis following cervical suppuration. Ann Surg 1938; 108: 588–611.
Downloaded from aan.sagepub.com at UNIV CALIFORNIA SAN DIEGO on June 4, 2015
614
Asian Cardiovascular & Thoracic Annals 21(5)
4. Marty-Ane´ CH, Berthet JP, Alric P, Pegis JD, Rouvie`re P and Mary H. Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease. Ann Thorac Surg 1999; 68: 212–217. 5. Freeman RK, Vallieres E, Verrier ED, Karmy-Jones R and Wood DE. Descending necrotizing mediastinitis: an analysis of the effects of serial surgical debridment on
patient mortality. J Thorac Cardiovasc Surg 2000; 119: 260–267. 6. Watson RW, Redmond HP, Mc Carthy J and BouchierHayes D. Taurolidine, an antilipopolysaccharide agent, has immunoregulatory properties that are mediated by the amino acid taurine. J Leukoc Biol 1995; 58: 299–306.
Downloaded from aan.sagepub.com at UNIV CALIFORNIA SAN DIEGO on June 4, 2015
Descending mediastinitis managed by sternotomy, taurolidine and delayed closure
Asian Cardiovascular & Thoracic Annals 21(5) 612–614 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312459045 aan.sagepub.com
Anand P Iyer, Gana Kugathasan, Ramesh Prabha, Paras Malik, Opeyemi Kuteyi and Robert Larbalestier
Abstract Descending necrotizing mediastinitis is a rare complication of upper respiratory infections. A quick diagnosis and prompt and complete surgical drainage is important for a successful outcome. A 74-year-old man with descending necrotizing mediastinitis needed a sternotomy, multiple washouts, and delayed sternal closure.
Keywords Abscess, bacterial infections, drainage, mediastinitis, taurolidine
Introduction Descending necrotizing mediastinitis (DNM) is a lifethreatening emergency after oropharyngeal infection. It is a serious infection involving the connective tissue that fills the pleural spaces and surrounds the median thoracic organs. The diagnosis must be established rapidly, and quick surgical treatment has to be given because the mortality rate could be as high as 60%.1 It usually occurs as a complication of severe cervical infection spreading along the facial planes into the mediastinum. Surgical management, particularly optimal mediastinal drainage, remains controversial with support ranging from cervical drainage alone to cervical drainage and routine thoracotomy. We describe a case in which there were pericardial abscesses requiring sternotomy, multiple washouts, and delayed sternal closure.
revealing a purulent discharge. Repeat CT showed multiple anterior and posterior mediastinal loculated collections. After sternotomy and drainage of all the abscesses, a good washout of the mediastinum and both pleural spaces was carried out with normal saline because there were empyemas on both sides. As the mediastinum was grossly infected, the sternum was not closed and Steri-Drapes were used to cover the wound. The pus grew multiple organisms both grampositive, gram-negative, and anaerobes. Broad-spectrum antibiotic treatment was initiated. The patient underwent mediastinal washout on 2 further occasions; on the last occasion, taurolidine was instilled into the mediastinum, and the sternum closed with mediastinal and pleural drains. He was extubated after few days and moved to the ward. He made a slow recovery and was eventually discharged.
Case report A 74-year-old man presented with febrile episodes and a swelling in the neck. Computed tomography (CT) showed a parapharyngeal abscess secondary to a tonsillar abscess. He underwent cervical drainage by ear, nose and throat surgeons. After admission to the intensive care unit, he did not improve, and bilateral neck exploration and washout was performed. His sepsis persisted and he had a small effusion that was drained,
Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, Australia Corresponding author: Anand P Iyer, MCh, Department of Cardiothoracic Surgery, Royal Perth Hospital, Wellington Street, Perth, WA 6000, Australia. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV CALIFORNIA SAN DIEGO on June 4, 2015
Iyer et al.
613
Figure 1. Computed tomography showing multiple mediastinal abscesses and bilateral empyema.
Discussion In 1983, Estrera and colleagues2 established the following diagnostic criteria for DNM: clinical signs and symptoms of severe neck infection; typical radiologic signs including fluid and/or gas collection on chest CT; intraoperative or post-mortem documentation of mediastinal infection; and continuity between the oropharyngeal infection and the mediastinal process. The incidence of DNM is low in the current era. In the first modern series of patients with DNM published in 1938, Pearse3 reported that 49% of patients died during treatment. In spite of the introduction of intravenous antibiotics, vast improvements in anaesthesia and critical care, and the development of CT imaging, the frequency of death in patients with DNM has remained high in the antibiotic era. Recent studies have revealed a significant reduction in mortality, as reported by Marty-Ane´ and colleagues4 and Freeman and colleagues.5 This could be attributed to early diagnosis and aggressive surgical treatment. Bacteriological analysis generally reveals mixed flora. The presence of mixed aerobic/anaerobic flora in the upper aerodigestive tract, in addition to limited numbers of immune-competent cells in the cervical mediastinum, explains why the infection spreads. The patient we treated had mixed aerobic and anaerobic organisms and was treated with broad-spectrum antibiotics. Bacteria excrete substances that are instrumental in this spread. Anaerobes have an affinity for the lipid components of cell membranes, and provoke muscle cell, erythrocyte, and platelet hydrolysis. The disease process cannot be controlled without complete excision of all necrotic tissue. Due to the anatomic relationships in the cervicothoracic region and the progressive nature of DNM, several approaches to mediastinal
drainage have been proposed: transcervical, subxiphoid, median sternotomy, clamshell incision, posterolateral thoracotomy, video-assisted mediastinoscopy, and video-assisted thoracoscopic surgery. Other treatment options include drainage of the collections using thoracotomy, or video-assisted thoracoscopic drainage. Both sides can be treated at the same sitting, or one side at a time. Video-assisted thoracoscopic techniques may also be used to drain mediastinal abscesses. The advantages of video-assisted thoracoscopic surgery are that it is less invasive, allows early recovery, and an open technique can always be employed if needed later. Sternotomy is more invasive and there is a risk of sternal osteomyelitis and impaired healing of the sternum under such circumstances. In view of the multiloculated nature of the disease, we decided to approach via a sternotomy which retrospectively turned out to be beneficial because the patient needed multiple washouts in view of ongoing sepsis. During the 3rd washout, we instilled taurolidine and closed the sternum. Taurolidine, bis(1,1-dioxoperhydro-1,2,4-thiadiazinyl-4)-methane, is a drug with antimicrobial and anti-lipopolysaccharide properties. Its immunue modulatory action is reported to be mediated by priming and activation of macrophages and polymorphonuclear leukocytes.6 It is used in Royal Perth Hospital for pleural washout in cyctic fibrosis patients, after pneumonectomy, and before transplanting a donor lung. Descending mediastinitis should be recognized quickly by imaging, and aggressively treated, because any delay could result in a fatal outcome. There are various ways by which it can be treated, and delayed surgical closure with washout and taurolidine instillation should be considered as an option. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Gorlitzer M, Grabenwoeger M, Meinhart J, Swoboda H, Oczenski W, Fiegl N, et al. Descending necrotizing mediastinitis treated with rapid sternotomy followed by vacuum-assisted therapy. Ann Thorac Surg 2007; 83: 393–396. 2. Estrera AS, Landay MJ, Grisham JM, Sinn DP and Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983; 157: 545–552. 3. Pearse HE. Mediastinitis following cervical suppuration. Ann Surg 1938; 108: 588–611.
Downloaded from aan.sagepub.com at UNIV CALIFORNIA SAN DIEGO on June 4, 2015
614
Asian Cardiovascular & Thoracic Annals 21(5)
4. Marty-Ane´ CH, Berthet JP, Alric P, Pegis JD, Rouvie`re P and Mary H. Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease. Ann Thorac Surg 1999; 68: 212–217. 5. Freeman RK, Vallieres E, Verrier ED, Karmy-Jones R and Wood DE. Descending necrotizing mediastinitis: an analysis of the effects of serial surgical debridment on
patient mortality. J Thorac Cardiovasc Surg 2000; 119: 260–267. 6. Watson RW, Redmond HP, Mc Carthy J and BouchierHayes D. Taurolidine, an antilipopolysaccharide agent, has immunoregulatory properties that are mediated by the amino acid taurine. J Leukoc Biol 1995; 58: 299–306.
Downloaded from aan.sagepub.com at UNIV CALIFORNIA SAN DIEGO on June 4, 2015
