Characteristics and Predictors of Mortality in Descending Necrotizing Mediastinitis: A Retrospective Cohort Study

Komang Adhitya Arya Adiputra ¹*, Dhihintia Jiwangga ², Mohamad Rizki ²

This study demonstrated key characteristics and mortality predictors in Descending Necrotizing Mediastinitis patients, aiding timely diagnosis and effective management strategies in Surabaya, Indonesia.

Abstract

Background: Descending necrotizing mediastinitis (DNM) is a life-threatening infection originating from necrotizing soft tissue infections, particularly in the cervical and oropharyngeal regions. DNM has a high mortality rate if not promptly diagnosed and treated surgically. Despite its severity, there is limited research on the characteristics and outcomes of DNM patients in Indonesia, especially in East Java. Methods: We conducted a single-center retrospective cohort study at Dr. Soetomo Hospital, Surabaya, Indonesia, analyzing the medical records of DNM patients treated between January 2021 and June 2023. Data on demographic, clinical, and surgical characteristics, along with treatment approaches, were collected. Statistical analyses included univariate and bivariate analyses to identify predictors of mortality. Results: Among 37 patients (mean age 45.6 years; 64.9% male), the primary infection source was odontogenic (86.5%). Most patients (51.4%) were classified as DNM type I, with cervicotomy and substernal drainage as the most common surgical approach (97.3%). The mean ICU stay was 6.6 days, and the overall hospital stay was 11.3 days. The mortality rate was 48.6%. Shorter hospital stays were significantly associated with increased mortality (p=0.000). Conclusion: DNM remains a severe condition with high mortality, primarily originating from odontogenic sources. Prompt diagnosis, appropriate surgical intervention, and targeted antibiotic therapy are critical to improving outcomes. Our study underscores the need for standardized management guidelines to enhance patient survival rates in regions with limited resources.

Keywords: Descending Necrotizing Mediastinitis, Mortality Predictors, Odontogenic Infections, Surgical Outcomes, Retrospective Cohort Study

References

AS, E., MJ, L., JM, G., DP, S., & MR, P. (1983). Descending necrotizing mediastinitis. Surg Gynecol Obstet, 157(6), 545–552.

Brunelli, A., Sabbatini, A., Catalini, G., & Fianchini, A. (1996). Descending Necrotizing Mediastinitis. Surgical Drainage and Tracheostomy. 122, 1326–1329.

Chen, K. C., Chen, J. S., Kuo, S. W., Huang, P. M., Hsu, H. H., Lee, J. M., & Lee, Y. C. (2008). Descending necrotizing mediastinitis: A 10-year surgical experience in a single institution. Journal of Thoracic and Cardiovascular Surgery, 136(1). https://doi.org/10.1016/j.jtcvs.2008.01.009

Deu-Martín, M., Saez-Barba, M., López Sanz, I., Alcaraz Peñarrocha, R., Romero Vielva, L., & Solé Montserrat, J. (2010). Factores de riesgo de mortalidad en la mediastinitis necrosante descendente. Archivos de Bronconeumología, 46(4). https://doi.org/10.1016/j.arbres.2010.01.008

Endo, S., Murayama, F., Hasegawa, T., Yamamoto, S., Yamaguchi, T., Sohara, Y., Fuse, K., Miyata, M., & Nishino, H. (1999). Guideline of surgical management based on diffusion of descending necrotizing mediastinitis. The Japanese Journal of Thoracic and Cardiovascular Surgery?: Official Publication of the Japanese Association for Thoracic Surgery = Nihon Kyobu Geka Gakkai Zasshi, 47(1). https://doi.org/10.1007/BF03217934

Foroulis, C. N. (2011). Descending Necrotizing Mediastinitis: Review of the Literature and Controversies in Management. The Open Surgery Journal, 5(1). https://doi.org/10.2174/1874300501105010012

Gorlitzer, M., Grabenwoeger, M., Meinhart, J., Swoboda, H., Oczenski, W., Fiegl, N., & Waldenberger, F. (2007). Descending Necrotizing Mediastinitis Treated With Rapid Sternotomy Followed by Vacuum-Assisted Therapy. Annals of Thoracic Surgery, 83(2). https://doi.org/10.1016/j.athoracsur.2006.09.059

Harar, R. P. S., Cranston, C., & Warwick-Brown, N. (2002). Descending necrotizing mediastinitis: Report of a case following steroid neck injection. Journal of Laryngology and Otology, 116(10). https://doi.org/10.1258/00222150260293745

Headley, A. J. (2003). Necrotizing soft tissue infections: A primary care review. In American Family Physician (Vol. 68, Issue 2).

Inaco Cirino, L. M., Elias, F. M., & de Almeida, J. L. J. (2006). Descending mediastinitis: A review. In Sao Paulo Medical Journal (Vol. 124, Issue 5). https://doi.org/10.1590/S1516-31802006000500011

Isowa, N., Yamada, T., Kijima, T., Hasegawa, K., & Chihara, K. (2004). Successful thoracoscopic debridement of descending necrotizing mediastinitis. Annals of Thoracic Surgery, 77(5). https://doi.org/10.1016/S0003-4975(03)01260-8

Jiwangga, D. (2018). Clinical characteristic and management of descending necrotizing mediastinitis: a retrospective study, Dr. Soetomo Hospital, Surabaya. Journal of Visualized Surgery, 4. https://doi.org/10.21037/jovs.2018.12.01

Krüger, M., Decker, S., Schneider, J. P., Haverich, A., & Schega, O. (2016). [Surgical treatment of acute mediastinitis]. Der Chirurg; Zeitschrift Fur Alle Gebiete Der Operativen Medizen, 87(6).

Lara, C. I. B., López, S. S., Ramos, A. S.-P., Martínez, A. A., Escobar, F. H., Valenzuela, F. Q., Zafra, F. J. R., & Guevara, A. C. L. de. (2013). Surgical management of descending necrotizing mediastinitis. Cirugía Española, 91(9), 579–583.

Makeieff, M., Gresillon, N., Berthet, J. P., Garrel, R., Crampette, L., Marty-Ane, C., & Guerrier, B. (2004). Management of Descending Necrotizing Mediastinitis. Laryngoscope, 114(4), 772–775. https://doi.org/10.1097/00005537-200404000-00035

Mazzella, A., Santagata, M., Cecere, A., La Mart, E., Fiorelli, A., Tartaro, G., Tafuri, D., Testa, D., Grella, E., Perrotta, F., Bianco, A., Mazzarella, G., & Santini, M. (2016). Descending necrotizing mediastinitis in the elderly patients. In Open Medicine (Poland) (Vol. 11, Issue 1). https://doi.org/10.1515/med-2016-0080

Min, H. K., Choi, Y. S., Shim, Y. M., Sohn, Y. I., & Kim, J. (2004). Descending necrotizing mediastinitis: A minimally invasive approach using video-assisted thoracoscopic surgery. Annals of Thoracic Surgery, 77(1). https://doi.org/10.1016/S0003-4975(03)01333-X

Palma, D. M., Giuliano, S., Cracchiolo, A. N., Falcone, M., Ceccarelli, G., Tetamo, R., & Venditti, M. (2016). Clinical features and outcome of patients with descending necrotizing mediastinitis: prospective analysis of 34 cases. Infection, 44(1). https://doi.org/10.1007/s15010-015-0838-y

Pearse, H. E. (1938). Mediastinitis Following Cervical Suppuration. Annals of Surgery, 108(4). https://doi.org/10.1097/00000658-193810000-00009

Putra, A., Satria, G., Bermansyah, Umar, A., & Nugraha, A. (2016). Characteristics of Patients of Descending Necrotizing Mediastinitis Thoracic, Cardiac and Vascular Surgery Subsection Thoracic in Dr. Mohammad Hoesin General Hospital. Sriwijaya Journal of Surgery, 04(2), 443–442.

Putra, M. A., Romolo, H., Syafina, A. B., Sani, A. A., Wuryantoro, Wardoyo, S., & Susanti, D. S. (2016). Descending necrotizing mediastinitis: Management and controversies. Cardiovascular and Thoracic Open, 2, 205555201667299. https://doi.org/10.1177/2055552016672997

Reuter, T. C., Korell, V., Pfeiffer, J., Ridder, G. J., Ketterer, M. C., & Becker, C. (2023). Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences—a retrospective follow-up study. European Archives of Oto-Rhino-Laryngology, 280(4). https://doi.org/10.1007/s00405-022-07769-x

Sugio, K., Okamoto, T., Maniwa, Y., Toh, Y., Okada, M., Yamashita, T., Shinohara, S., Yoshino, I., Chida, M., Kuwano, H., & Shiotani, A. (2021). Descending necrotizing mediastinitis and the proposal of a new classification. JTCVS Open, 8. https://doi.org/10.1016/j.xjon.2021.08.001

Sumi, Y. (2015).  Descending necrotizing mediastinitis: 5 years of published data in J apan . Acute Medicine & Surgery, 2(1), 1–12. https://doi.org/10.1002/ams2.56

Ulusan, A., & Koc, I. (2016). Descending necrotizing mediastinitis. Ulutas Med J, 1(1), 1–6. https://doi.org/10.4155/9781910420287.FSEB2013.14.278

Uwa, N., Terada, T., Saeki, N., Sagawa, K., Ogino, K., & Sakagami, M. (2010). Clinical features of 5 patients with descending necrotizing mediastinitis originating from deep neck infection. Auris Nasus Larynx, 37(4). https://doi.org/10.1016/j.anl.2009.11.005

Weaver, E., Nguyen, X., & Brooks, M. A. (2010). Descending necrotising mediastinitis: Two case reports and review of the literature. In European Respiratory Review (Vol. 19, Issue 116). https://doi.org/10.1183/09059180.00001110

Yun, J. S., Lee, C. H., Na, K. J., Song, S. Y., Oh, S. G., & Jeong, I. S. (2023). Surgical Experience with Descending Necrotizing Mediastinitis: A Retrospective Analysis at a Single Center. Journal of Chest Surgery, 56(1). https://doi.org/10.5090/jcs.22.110