1 - Serviço de Cirurgia Pediátrica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
2 - Serviço de Cirurgia Torácica, Hospital Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisboa
- Apresentação oral no 1º congresso Luso-brasileiro de Cirurgia Torácica – SPCCTV – 4D Visions, Going Critical.
Introduction: Descending necrotizing mediastinitis (DNM) is a rare, life-threatening complication arising from oropharyngeal and cervical infections that spreads into the mediastinum. While predominantly observed in adults, cases in the pediatric population are increasingly being reported. It represents a true surgical emergency requiring early diagnosis and effective multidisciplinary therapeutic strategy. The aim of this study is to analyze the clinical characteristics and review the management options applied to the new surge of DNM pediatric cases.
Methods: We retrospectively analyzed all patients with DNM who underwent mediastinum surgical drainage in our institution between 2017 and 2023. DNM was diagnosed based on the criteria proposed by Estrera et al. We applied the Endo et al pathological classification, modified by ESTS.
Results: 3 patients were included over a 7-year period, all cases detected in 2023. Mean age was 2,6 (±1.15) years, with male predominance 2:1. The most prevalent underlying cause observed was parapharyngeal abscess (100,0%). All patients presented with cervical infection. 1 patient was considered a type I; 1 patient was type IIC and the last one was classified as type III due to pleural involvement. All patients underwent combined ENT and thoracic surgery approach. All patients were submitted to a transoral approach. Our type I patient only required additional cervicotomy, whilst the other 2 needed a combined approach through cervicotomy and thoracotomy. A total of 4 surgical drainage procedures were accounted. Only 1 of the patients needed a reoperation. The mean ICU and hospital stay was 6,6 (±2,3) days and 33,7 (±23,8), respectively. The main isolated bacteria in blood cultures were Streptococcus pyogenes. Other agents were Streptococcus constallatus and Prevotella veroralis, commensal bacteria of the oral cavity. Broad-spectrum antibiotics was administered independently of agent isolation due to DNM being typically a polymicrobial infection. No deaths occurred and, at the moment, all patients remain asymptomatic without evidence of complications.
Conclusion: The importance of early recognition and aggressive intervention in DNM cannot be overstated, as delayed treatment can lead to high mortality rates. In the pediatric population, there is a need for a heightened clinical suspicion, rapid diagnosis, and multidisciplinary care to optimize outcomes. This new surge of severe infections in children described in recent literature (streptococcic and staphylococcic upper and lower airway infections) might be a consequence of children being less exposed to common pathogens during covid-19 lockdown in the early years of development.
Palavras Chave: descending necrotizing mediastinitis; pediatric; surgical drainage; thoracic surgery