A Case of Descending Necrotizing Mediastinitis.

Lee, In Soo; Choi, Hwan Jun; Lee, Han Jung; Lee, Jae Wook; Lee, Dong Gi

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Case Report

Journal of the Korean Society of Plastic and Reconstructive Surgeons 2009;36(3):351-355.
Published online May 1, 2009.

A Case of Descending Necrotizing Mediastinitis.

In Soo Lee, Hwan Jun Choi, Han Jung Lee, Jae Wook Lee, Dong Gi Lee

¹Department of Plastic and Reconstructive Surgery, College of Medicine, Soonchunhyang University, Gyeongbuk, Korea. medi619@hanmail.net
²Department of Thoracic and Cardiovascular Surgery, College of Medicine, Soonchunhyang University, Gyeongbuk, Korea.
³Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Gyeongbuk, Korea.

Abstract

PURPOSE
Cervical necrotizing fasciitis tends to involve the deep soft tissues and spread caudally to the anterior chest and mediastinum, often resulting in major complications and death. It may rapidly spread into the thorax along fascial planes, and the associated diagnostic delay results in this descending necrotizing mediastinitis. So, aggressive multidisciplinary therapy with surgical drainage is mandatory. We present a very rare case of descending necrotizing mediastinitis with literature review. METHODS: A 53 years old male visited our department 7 days after trauma in neck. His premorbid conditions and risk factors of necrotizing fasciitis were concealed hepatoma, trauma history, chronic liver disease, and nutrition deficit. Computed tomographic scans of the head and neck region were performed in this patient: signs of necrotizing fasciitis, were seen in the platysma, sternocleidomastoid, trapezius muscle and strap muscles of the neck. Fluid accumulations involved multiple neck spaces and mediastinum. At the time, he diagnosed as necrotizing fasciitis on his neck and anterior chest. Necrotic wound was excised serially and we treated this with the Vacuum-assisted closure (VAC, Kinetics Concepts International, San Antonio, Texas) system device. After appropriately shaping the sponge and achieving additional 3 pieces drainage tubes in the pockets, continuous negative pressure of 125 mmHg was applied. The VAC therapy was applied for a period of 12 days.
RESULTS
We obtained satisfactory results from wide excision, abscess drainage with the VAC system, and then split thickness skin graft. The postoperative course was uneventful.
CONCLUSION
The refined technique using the VAC system can provide a means of simple and effective management for the descending necrotizing mediastinitis, with better cosmetic and functional results. Finally, the VAC system has been adopted as the standard treatment for deep cervical and mediastinal wound infections as a result of the excellent clinical outcome.

Keywords: Cervical; Necrotizing fasciitis; Desceding necrotizing mediastinitis; Vacuum assisted closure system

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