下行性坏死性纵隔炎的临床诊断与治疗

Diagnosis and Therapy of Patients with Descending Necrotizing Mediastinitis

目的探讨下行性坏死性纵隔炎（DNM）患者的临床诊断和治疗,为临床提高该病的早期诊断率和治愈率提供依据。方法回顾分析2006~2009年第四军医大学唐都医院诊治的8例DNM患者的临床资料,其中男7例,女1例;中位年龄49.5（21~98）岁。依据患者临床表现,颈、胸部CT扫描特征和分泌物细菌培养结果确诊。其中牙源性感染6例,合并糖尿病6例。治疗方法包括积极抗感染和手术切开引流等。本组患者仅行颈部切开、引流术2例,开胸手术5例,胸腔镜手术1例。结果痊愈6例,死亡2例,其中1例死于心功能衰竭,1例死于颈部血管破裂出血。细菌培养混合感染者6例,其中需氧菌和厌氧菌混合感染者4例。手术时间平均75.6 min,术中平均引流脓液量318.7 ml,平均住院时间18 d。6例生存患者随访6个月,生活质量提高。结论患者病史、症状和体征,颈、胸部CT检查和分泌物细菌培养是确诊DNM的有效方法。早期、足量应用广谱抗生素,根据CT分型采取个体化的切开引流,有效处理糖尿病等合并症和支持治疗是降低病死率的有效手段。

Objective To explore the diagnosis and treatment of descending necrotizing mediastinitis（DNM）.Methods We retrospectively analyzed the records of eight DNM patients treated at Tangdu Hospital between 2006 and 2009 year.There were 7 males and 1 female aged from 21-98 years with a median age of 49.5 years.The diagnostic criteria included clinical manifestations,neck and chest CT scans,and bacteriological culture.Six of the patients had odontogenic infections and six had diabetes.Antibiotic treatment,incision drainage,and other symptomatic treatments were applied.Two patients received cervical incision drainage,five received thoracotomy,and one received video-assisted thoracoscopic surgery（VATS）.Results After treatment,six patients recovered and two died of heart failure and neck vessel rupture.According to the bacterial culture,six patients presented mixed infections,and four of these presented mixed aerobic and anaerobic infections.The mean operation time was 75.6 minutes,the average volume of pus removed during the operation was 318.7 ml,and the average inpatient stay was 18 days.At six months follow-up,all six surviving patients showed improvements in quality of life.Conclusion The valid diagnosed criteria of DNM include history,sign,symptom,neck and chest CT scanning,and secretion culture.DNM mortality can be reduced by employing broad spectrum antibiotics early in treatment,individual surgical managements,and effective treatments for complicating illnesses.