下行性坏死性纵隔炎：一项基于我国近10年已发表数据的临床分析

Descending necrotizing mediastinitis: a clinical analysis based on 10 years of published data in China

摘要

目的 探讨下行性坏死性纵隔炎（descending necrotizing mediastinitis，DNM）的临床特征、诊治策略、预后，为早期诊断、及时治疗DNM提供参考。方法 计算机检索我国已发表的DNM文献（2012年6月至2023年6月）并进行全面回顾评估，分析DNM感染原因、致病微生物、主要症状、合并症、治疗方法等。结果 共检索到781例DNM病例，平均年龄（52.97 ± 5.64）岁，其中554例男性，227例女性。牙源性感染来源、扁桃体和咽喉脓肿、唾液腺炎、上呼吸道感染、异物损伤或医源性创伤操作是DNM常见病因的来源，其中牙源性感染来源最多见。链球菌属（n = 217）和葡萄球菌属（n = 82）是感染灶最常分离得到的菌群，其次是肺炎克雷伯杆菌和铜绿假单胞菌（均为59例）。有69.4%（542/781）的DNM患者存在各种合并症，其中超过1/3的患者（n = 185）患有糖尿病。碳青霉烯类是治疗DNM最广泛应用的抗生素，万古霉素则是最多的联合用药选择。纵隔引流方法变化多样，但最佳方案尚存争议。本研究发现，72例DNM患者接受了电视辅助胸腔镜/纵隔镜手术引流，22例患者经皮穿刺引流，30例患者单独采用经颈平行入路引流，40例患者进行了开胸手术，617例根据感染病灶具体部位选择相应联合术式进行外科引流。781例DNM患者总死亡率为11.2%。结论 DNM最有效的诊治措施为保持高度的临床警觉，及时采取充分的外科引流，并进行重症监护，包括血流动力学监测和营养支持以及必要多次的计算机断层扫描检查、全身抗生素联合用药。

Abstract

Objective To investigate the clinical characteristics, diagnosis, treatment, and prognosis of descending necrotizing mediastinitis (DNM) to provide a reference for the early diagnosis and timely treatment of DNM. Methods Data on DNM in China was electronically retrieved from the core databases and comprehensively reviewed from June 2012 to June 2023. The infection, pathogenic microorganisms, main symptoms, comorbidities and treatment methods of DNM were analyzed. Results The data of a total of 781 DNM patients, with an average age of (52.97 ± 5.64) years, were retrieved, including 554 males and 227 females. Odontogenic source, tonsillitis, pharyngeal abscess, sialoadenitis, upper respiratory tract infection, foreign body injury, or iatrogenic traumatic procedures are common causes. Among these, odontogenic infection is the most common source. Streptococcus sp. (n = 217) and Staphylococcus sp. (n = 82) were most isolated, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa (equally n = 59). A total of 69.4% (542/781) of DNM patients recruited in this study were discovered to have various comorbidities, and more than one-third of these patients (n = 185) had diabetes. Of the broad antibiotics, carbapenem was most frequently used as treatment, and vancomycin was the most frequently coadministered. The mediastinal drainage approach varies widely, and the optimal regimen is still unknown. Seventy-two patients were treated with video-assisted thoracoscopic/mediastinoscopic surgical drainage, 22 patients were treated with percutaneous catheter drainage, 30 underwent the transcervical approach, and 40 underwent thoracotomy. A total of 617 patients who were selected underwent the appropriate combined operation for surgical drainage according to the specific location of the infected focus. The overall mortality rate of all 781 DNM patients included was 11.2%. Conclusion The most effective diagnosis and treatment of DNM is a high degree of clinical vigilance followed by prompt and adequate drainage with intensive care, including hemodynamic monitoring, nutritional support, computer tomographic scanning repeated as necessary, and combined use of systemic antibiotics.

关键词

牙源性感染 / 腺源性感染 / 口腔颌面部多间隙感染 / 颈部坏死性筋膜炎 / 下行性坏死性纵隔炎 / 回顾性分析 / 循证医学

Key words

odontogenic infection / glandular infection / oral and maxillofacial multispace infection / cervical necrotizing fasciitis / descending necrotizing mediastinitis / retrospective analysis / evidence-based medicine

Author summay

李晨曦，主治医师，博士，Email: [e-mail]