1/40. guideline of surgical management based on diffusion of descending necrotizing mediastinitis.BACKGROUND: Descending necrotizing mediastinitis resulting from oropharyngeal abscess, is a serious, life-threatening infection. Exisiting strategies for surgical management, such as transcervical mediastinal drainage or aggressive thoracotomic drainage, remain controversial. methods: Four patients, (three males and one female) were treated for descending necrotizing mediastinitis resulting from oropharyngeal infection. Two had peritonsillar abscesses, while the others experienced dental abscess and submaxillaritis. Descending necrotizing mediastinitis received its classification according to the degree of diffusion of infection diagnosed by computed tomography. mediastinitis in two cases, (Localized descending necrotizing mediastinitis-Type I), was localized to the upper mediastinal space above the carina. In the others, infection extended to the lower anterior mediastinum (Diffuse descending necrotizing mediastinitis-Type IIA), and to both anterior and posterior lower mediastinum (Diffuse descending necrotizing mediastinitis-Type IIB). The spread of infection to the pleural cavity occurred in three cases. RESULTS: The surgical outcome concerning each of the patients was successful. Radical cervicotomy (unilateral in three patients, bilateral in the other) in conjunction with mechanical ventilation with continuous postoperative positive airway pressure, was performed in all cases. tracheostomy was established in three patients and pharyngostomy in two. The two descending necrotizing mediastinitis-Type I cases were successfully managed with transcervical mediastinal drainage. The descending necrotizing mediastinitis-Type IIA case received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoidal incision. The patient with descending necrotizing mediastinitis-Type IIB required posterior mediastinal drainage through a right standard thoracotomy followed by left minimal thoracotomy. CONCLUSIONS: The mediastinal infection, the extent of which has been accurately determined by computed tomograms, necessitates radical cervicotomy followed by pleuromediastinal drainage. Situations where infection has spread to posterior medisatinum, particularly when it reaches in the level of the carina (descending necrotizing mediastinitis-type I), may not always require aggressive mediastinal drainage. In comparison, diffuse descending necrotizing mediastinitis-Type IIB demands complete mediastinal drainage with debridement via thoracotomy. Subxiphoidal mediastinal drainage without sternotomy may provide adequate drainage in diffuse descending necrotizing mediastinitis-Type IIA.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
2/40. Descending suppurative mediastinitis: nonsurgical approach to this unusual complication of retropharyngeal abscesses in childhood.OBJECTIVE: To alert the pediatric emergency physician about suppurative mediastinitis as an unusual, life-threatening complication of retropharyngeal abscesses in children and to report an alternative therapeutic option for these cases. methods: We describe a case of suppurative mediastinitis secondary to a retropharyngeal abscess in a 19-month-old girl and discuss the pathophysiology, diagnosis, and treatment of this disease. RESULTS: Prompt diagnosis, based on clinical, radiographic, and CT findings, followed by immediate retropharyngeal drainage and appropriate antibiotic therapy, allowed conservative management of the mediastinal abscess, without the need for surgery. The child presented a good outcome and was discharged on hospital day 14. CONCLUSIONS: When evaluating a retropharyngeal abscess, the pediatric emergency physician should be aware of its complications. A chest radiograph should be prescribed for each patient presenting with an indolent course. Widening of the mediastinum should be considered as strong evidence of a mediastinal abscess for which the best therapeutic option is aggressive surgical drainage. In the rare cases in which marked improvement is achieved after retropharyngeal drainage, a nonsurgical approach to the mediastinal abscess could be attempted. CT scan and a simple chest radiograph have proved to be useful for diagnosis and follow-up.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
3/40. Fatal mediastinitis after routine laparoscopic cholecystectomy.Laparoscopic cholecystectomy is now considered a routine operation with a low complication rate. In this case study, the authors present a laparoscopic cholecystectomy patient who died of masked mediastinitis and concomitant septicemia caused by an unrecognized esophageal perforation after difficult intubation. The authors call attention to the need for early detection of perforating mediastinitis to prevent a lethal outcome from this infrequent but life-threatening condition.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
4/40. Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery.Mediastinal sepsis following open heart surgery is a significant cause of death. Open drainage of the mediastinumalone was employed originally in management of this problem. More recently, debridement, drainage, and reclosure have been used. Various irrigation solutions, such as antibiotics and Betadine, have been advocated to control severe mediastinal sepsis. Three principles of management in patients unresponsiveness to the above techniques have proved successful in two patients with life-threatening mediastinal sepsis: (1) radical, complete excision of the sternum and adjacent costal cartilages; (2) transposition of the greater omentum on a vascular pedicle to the mediastinum; and (3) primary closure with full-thickness rotational skin flaps. The radical excision of the sternum removes residual foci of sepsis in cartilage and sternal bone marrow. The transposition of the omentum provides a highly vascular, rapidly granulating covering for the contaminated great vessels and hase been successfully to prevent recurrence of suture line bleeding of an exposed ascending aortic anastomosis site. Primary closure of the wound with full-thickness skin flaps provides a suprisingly satisfactory covering for the heart. Preoperative and postoperative measurements of ventilatory mechanics have shown relatively small ventilatory impairment after the alteration of the thoracic cage imposed by excision of the sternum. Two patients have returned to active lives. A treatment failure probably due to incomplete adherence to these guidelines also is presented.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
5/40. Omental flap for mediastinitis after median sternotomy in asplenia syndrome and gut malrotation.We describe a 12-year-old patient with asplenia syndrome and gut malrotation who, after an interim step before a modified Fontan operation, developed life-threatening mediastinitis. A flap of the omentum arising from the transverse colon, longitudinally located in the left of the abdomen, was created and transferred to the mediastinum after a division of the arterial arcade at its most caudal extent. Her postoperative course was uneventful, and 12 months later, the modified Fontan operation was successfully completed. Although visceral heterotaxy results in an omental deformation, it does not preclude the use of an omental flap.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
6/40. Successful in situ treatment of an infected ascending aortic graft.Infection of an ascending aortic prosthesis is a grave complication associated with a high mortality. In most cases, extraanatomic bypass and removal of the infected vascular graft are not possible. Furthermore, the standard approach to this problem, which includes excision and replacement or debridement and repair of infected thoracic aortic grafts, carries a high early mortality. We report the successful treatment of this life-threatening complication using a conservative strategy in which the aortic prosthesis was salvaged by in situ disinfection followed by coverage with tissue flaps.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
7/40. Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases.PURPOSE: Although most cases of cervical necrotizing fasciitis (CNF) are odontogenic in origin, reports of this disease in the dental literature are sparse. The purpose of this study was to review the cases treated on our service, and to analyze the features of this disease and the responses to management, to supplement the understanding of this relatively rare and life-threatening disease. patients AND methods: All cases of infection admitted to the OMS service in a period of 10.5 years were studied retrospectively. The diagnosis of CNF was established by the findings on surgical exploration and histologic examination. The patients' age, sex, medical status, causes of the infection, bacteriology, computed tomography scan findings, surgical interventions, complications, survival, and other clinical parameters were reviewed. RESULTS: A total of 422 cases of infection were admitted, and 11 cases of cervical necrotizing fasciitis were found. The incidence of CNF was 2.6% among the infections hospitalized on the OMS service. There were 7 male and 4 female patients. Eight patients were older than 60 years of age. Seven patients had immunocompromising conditions, including diabetes mellitus in 4, concurrent administration of steroid in 2, uremia in 1, and a thymus carcinoma in 1. All patients showed parapharyngeal space involvement; four also showed retropharyngeal space involvement. Gas was found in the computed tomography scan in 6 patients, extending to cranial base in 3 of them. Anaerobes were isolated in 73% of the infections, whereas streptococcus species were uniformly present. All patients received 1 or more debridements. Major complications occurred in 4 patients, including mediastinitis in 4, septic shock in 2, lung empyema in 1, pleural effusion in 2, and pericardial effusion in 1. All major complications developed in the immunocompromised patients, leading to 2 deaths. CONCLUSION: The mortality rate in this study was 18%. Early surgical debridement, intensive medical care, and a multidisciplinary approach are advocated in the management of CNF.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
8/40. Infection of a retained permanent epicardial pacemaker lead.Infection of a retained permanent epicardial pacemaker lead rarely causes mediastinal infection. A 21-month-old boy who had undergone an arterial switch operation at day 6 of life presented with mediastinal infection 3 months after removal of the generator. Removal of the infected pacemaker leads with the inflammatory granuloma was performed under extracorporeal circulation. The mediastinal infection developed from the retained epicardial pacemaker lead infection.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
9/40. A rare complication of tooth abscess--ludwig's angina and mediastinitis.Deep neck infections are a rare but potentially fatal complication of pulpal abscess of the teeth. If an infection can progress rapidly from a toothache to a life-threatening infection, then it is critical that dentists be able to recognize the danger signs and identify the patients who are at risk. This article reviews a case of a seemingly innocuous toothache which rapidly progressed to ludwig's angina and mediastinitis, and discusses how to recognize and manage these life-threatening infections.- - - - - - - - - - ranking = 2keywords = life (Clic here for more details about this article) |
10/40. Regarding three cases of descending necrotizing mediastinitis: spiral CT assessment.Descending necrotizing mediastinitis (DNM) is a rare and life-threatening complication of deep neck space infection which occurs when infection spreads from the deep spaces of the neck, propagating within the soft tissue into the mediastinal spaces. The disease has a high mortality rate due to frequent delay in diagnosis and treatment. Computed tomography (CT) is important in determining the level of infection, showing the presence and extension of fluid collections (with or without gas bubbles) and diffuse soft-tissue infiltration of the mediastinal fat, and indicating the best surgical approach and progress of treatment. Three cases of DNM evaluated with spiral CT from June 1999 to June 2001 are presented.- - - - - - - - - - ranking = 1keywords = life (Clic here for more details about this article) |
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