A Case of Descending Necrotizing Mediastinitis with Mediastinoscopic Drainage of a Residual Abscess by the Subxiphoid Approach

Abstract

A 72-year-old woman was referred to our hospital with acute kidney injury and poor oxygenation during treatment for pyogenic pharyngitis. The patient was diagnosed with descending necrotizing mediastinitis (DNM), septic shock, and bilateral pyothorax. Emergency cervical incision and bilateral thoracic cavity drainage were performed. However, computed tomography on postoperative day 14 suggested enlargement of the anterior mediastinal remnant abscess. As severe pleural adhesions caused by the pyothorax were expected, reoperation using the subxiphoid approach was selected instead of the trans thoracic approach. The abscess was drained using an endoscopic ultrasound probe. The patient was discharged on day 64 after admission without recurrence. Treatment of DNM often requires redrainage because of the remaining abscess after the first surgery. If reoperation is considered, a minimally invasive and appropriate approach should be selected, considering the patient's tolerance and postoperative adhesions. Moreover, an intraoperative endoscopic ultrasound probe was useful for abscess identification.