Etiology, diagnosis, and management of descending necrotizing mediastinitis: a narrative review.

Background and Objective: Descending necrotizing mediastinitis (DNM) is a severe and life-threatening infection that originates from oropharyngeal or cervical infections and spreads downward into the mediastinum. Despite advancements in medical and surgical treatments, DNM remains a condition with high morbidity and mortality. This narrative review aims to summarize the etiology, diagnostic strategies, and management approaches for DNM, emphasizing the importance of a multidisciplinary approach. Methods: A comprehensive literature search was conducted using PubMed/MEDLINE, Western University Libraries, and Google Scholar databases, without restriction on publication date. Articles were included if they discussed: (I) the etiology of mediastinitis, focusing on anatomy and pathogens; (II) the diagnosis of DNM; and (III) the treatment and surgical approach to mediastinitis. Key Content and Findings: DNM is commonly caused by oropharyngeal infections that spread downward through normal anatomical pathways. Diagnosis is challenging due to the subtle and varied presentation of symptoms. Diagnosis is primarily made with contrast-enhanced CT scans of the neck and thorax, but a convincing history should prompt appropriate suspicion and concern. Management requires a multidisciplinary approach, including sepsis management particularly with broad-spectrum antibiotics and early surgical intervention for source control. The choice of surgical technique, whether transcervical, thoracotomy, or video-assisted thoracoscopic surgery (VATS), is crucial for effective drainage and reducing mortality. Conclusions: DNM is a complex and critical condition that demands prompt recognition and aggressive treatment. The high mortality associated with DNM underscores the need for a multidisciplinary approach. Surgical drainage, tailored to the extent of the infection, and comprehensive post-operative care are essential for improving patient outcomes. Future research should focus on optimizing diagnostic criteria, refining surgical techniques, and exploring adjunct therapies to further reduce morbidity and mortality in DNM.