Patients and methods
After obtaining approval from the Institutional Review Board of our
institution, retrospective chart reviews were undertaken for patients
with DNI between March 2006 and June 2019. Among these patients, those
who had shown downward involvement of necrotizing mediastinitis on chest
CT were selected. Patients with mediastinitis resulting from an
iatrogenic esophageal perforation and cervical spine fracture were
excluded. Data including personal demographics, image studies,
laryngoscopy findings, anesthesia records, operation records, and
hospital courses were carefully collected. Initial status of upper
airway was evaluated with a flexible laryngoscope (Machida Instruments,
Tokyo, Japan) on an emergency basis. Details of difficult airway and
orotracheal intubations were graded based on the anesthesiologist’s
report, estimating difficulty of laryngeal exposure and intubation time.
All patients initially received empirical broad-spectrum intra-venous
antibiotics such as ceftriaxone and clindamycin after neck infection was
identified on CT. Once the causative pathogen was cultured, antibiotics
were adjusted according to results of sensitivity tests.
Patients were evaluated according to Endo and colleagues’ classification
about the degree of diffusion of DNM based on chest CT findings. For
type I, the infection was localized in the upper mediastinum above the
carina. For type IIA, the infection extended to the lower anterior
mediastinum. For type IIB, the infection extended to lower anterior and
posterior portions of the mediastinum.3 Involved
cervical spaces were opened, drained, and debrided of necrotic tissues.
Various types of mediastinal drainage including transcervical, lateral
thoracotomy approach, and video-assisted thoracic surgery (VATS) were
selected according to Endo classification.