Descending Necrotizing Mediastinitis, When Mediastinal Drainage By Thoracoscopy Is Not Sufficient: Case Report and Review of the Literature.

Introduction: Descending necrotizing mediastinitis (DNM) is an acute infection of the mediastinum secondary to odontogenic, pharyngeal, or cervical infections that extend into the deep cervical spaces and progress into the mediastinum. This case report and literature review aim to contribute to the understanding of DNM and emphasize the importance of the surgical approach in its treatment. Presentation of the case: A 28 year old male with no relevant history, consulted a fourth level institution after presenting upper respiratory symptoms. CT scans revealed compatible findings with type II DNM plus bilateral pleural empyema. Pleural and mediastinal drainage, pleurectomy, and pulmonary decortication were performed using bilateral thoracoscopy. Cervical drainage via cervicotomy was subsequently required. Antibiotic treatment was continued for 6 weeks. For the literature review, a search was conducted in PubMed, Elsevier, and Scielo, yielding 35 articles published between 1938 and 2024, of which 22 were selected by the authors. Discussion: Treatment of DNM requires broad-spectrum antibiotics and timely surgical drainage. The approach must depend on the anatomical extent of the disease. Endo's classification, revised by Sugio, allows appropriate staging and surgical guidance. Mediastinal drainage can be performed via thoracotomy or video-assisted thoracoscopy, and it often needs to be complemented with cervicotomy for adequate infection control. Conclusion: This case exemplifies the pivotal role of anatomical classifications as a tool to guide the surgical approach. Nonetheless, more evidence is still needed to standardize management. Detailed knowledge of the pathophysiology and the pathways of dissemination allows for the Implementation of effective surgical strategies tailored to each patient.