Atypical Surgical Management of Descending Necrotizing Mediastinitis in a Resource-Limited Country: Prise en Charge Chirurgicale Atypique d'une Médiastinite Nécrosante Descendante dans un Pays aux Ressources Limitées

Abstract

Descending necrotising mediastinitis is an infection whose early diagnosis is often non-specific, but late diagnosis, which is more specific, is generally associated with high mortality. We report the case of a teenage girl referred for suspected lower cervical cellulitis, originating in the teeth, which had been developing for more than three weeks prior to her admission. Upon admission, she presented with symptoms of lower neck pain, without dysphagia, trismus or dysphonia, but associated with limited neck mobility. The patient also presented with progressive dyspnoea, associated with hyperthermia measured at 38.7 degrees Celsius. Chest CT scan revealed a retrosternal and sternoclavicular fluid collection associated with manubrial bone lacunae. After taking preoperative blood tests, the surgical indication was set as debridement and flattening by sternotomy under general anaesthesia, supplemented by vacuum-assisted therapy. Intraoperative exploration revealed pre- and retrosternal purulent collections, which were aspirated and washed with 9% saline solution. The postoperative course was uneventful, and the patient remained in hospital for 14 days. Irrigation and drainage continued for one week after admission, and the vacuum assisted closure was removed after 10 days. The patient's clinical condition improved, with the pain disappearing and her biological tests returning to normal. Given the encouraging results of this procedure, which is suited to an atypical clinical form of this condition, it would be wise to consider it and make it more widely available in countries with limited resources.