Narrative review of descending necrotizing mediastinitis, focusing on the etiology, classification-guided surgical management, treatments, and prognosis

Introduction

Background

Descending necrotizing mediastinitis (DNM) is an acute, life-threatening infection originating from an oropharyngeal or cervical infection into the mediastinal space through the deep cervical fascial planes, which was first described by Pearse in 1938 (1). DNM is one of the most severe complications of deep neck infection (DNI), with untreated cases historically exhibiting extremely high mortality rates of 15.5–35% (2-5). Recent advances in diagnostic imaging, surgical techniques, intensive care, and antimicrobial therapy have improved outcomes, with less than 10% mortality (6), as described in selected contemporary cohorts or registry data, whereas pooled estimates derived from broader datasets are higher. To further improve outcomes, it is essential for early recognition and prompt intervention (7-11).

An anatomical classification system based on mediastinal extent was first proposed by Endo et al. in 1999 (12). In 2021, our group proposed a new classification of DNM to provide a guide for its surgical treatment, focusing on the type of extension and the deployed procedures, using a multicenter observational study (13). Early recognition of the type of extension into the mediastinal space is significantly associated with the outcome of this disease (14,15). The details of this study are explained in this review.

Rationale and knowledge gap

To further improve outcomes, early recognition and prompt intervention are crucial (7-11,16-18). Because DNM is a relatively rare disease in practice, individual hospitals are inexperienced in treating it (19). Although a recent large-scale multicenter study provided detailed real-world data from specialized hospitals (13), the optimal surgical management of this disease remains under debate.

Objective

We reviewed original articles on this topic published since 1999. The objective of this review article was to analyze the historical development of DNM and outline its pathophysiology, diagnostic modalities, and treatment strategies based on disease extension, with the goal of addressing the current knowledge gap. We present this article in accordance with the Narrative Review reporting checklist (available at https://med.amegroups.com/article/view/10.21037/med-2025-1-46/rc).

Methods

We conducted a literature review on DNM. A structured literature search of PubMed/MEDLINE was performed from January 1999 to June 2025 using the term “descending necrotizing mediastinitis”. The inclusion criteria were as follows: articles written in English at least in abstract; no restrictions were placed on article type (e.g., case reports, case series, cohort studies, and review articles), provided that the report addressed the etiology, pathophysiology, anatomical classification, surgical approach and treatment, or outcome of DNM. For quantitative tabulations, only articles reporting ≥4 patients were included. Less than 4 patients case-reports, although potentially informative, were not included in the quantitative summaries. Review-type articles were used only to provide narrative context and to identify additional primary studies, and were not included in the numerical analysis to avoid double counting. The exclusion criteria were conference proceedings and experimental animal studies. A summary of our search strategies is presented in Table 1. The search was performed on July 19 and August 27, 2025. Full texts were retrieved through the Oita University Library.

All retrieved records were screened and eligibility was assessed independently by two reviewers (K.S. and K.K.), and data extraction was also performed independently by the same reviewers. As shown in Table S1, 60 articles were included in this analysis.

Content review

Etiology

Pathophysiology and routes of spread

DNM is a highly lethal condition characterized by the rapid extension of DNI into the mediastinum through interconnected fascial planes of the neck and thorax (3,4,20,21). Understanding the anatomical and pathophysiological mechanisms underlying this process is critical for an early diagnosis, effective surgical planning, and timely source control (22).

Origin of infection

We reviewed 52 original articles published between 1999 and 2025 in which the site of origin was specified. The findings are summarized in Table S1. DNM most frequently originates from oropharyngeal or odontogenic infections (23-25). Common antecedent conditions include cervical infections, peritonsillar or retropharyngeal abscesses, pharyngitis, tonsillitis, epiglottitis, esophageal, postoperative or traumatic cervical infections. These primary infections may evolve into DNI, which serve as the nidus for mediastinal extension, particularly in elderly patients with diabetes or immunocompromised patients when diagnosis and treatment are delayed (26).

Risk factors for DNM among patient characteristics include poor dental hygiene, diabetes, intravenous drug abuse, excessive alcohol intake, AIDS and recent steroid use. Makeieff et al. (7) reported that, among 17 patients, 3 patients had insulin-dependent diabetes mellitus, including with poorly controlled diabetes who presented with metabolic acidosis at admission. Despite therapeutic intervention, the patient could not be saved. Poorly controlled diabetes has been identified as a risk factor for a fatal course (27,28), which may contribute to impaired tissue oxygenation. The authors emphasized that reduced tissue oxygenation enhances the pathogenicity of anaerobic bacteria, thereby facilitating the progression and spread of infection.

The transitions of the sites of origin are summarized in Table 2. Overall, the majority of cases originated from pharyngeal, laryngeal, or tonsillar sites, followed by odontogenic sites. From 2000 to 2009, the most common sites were pharyngeal/laryngeal/tonsillar (55.6%, n=99) and odontogenic (39.8%, n=71). A similar pattern was observed in 2010–2019, with pharyngeal/laryngeal/tonsillar cases comprising 56.1% (n=184) and odontogenic lesions comprising 32.3% (n=106). In 2020–2025, odontogenic cases accounted for 39.8% (n=422), whereas the proportion of pharyngeal/laryngeal/tonsillar cases declined to 40.3% (n=427). Although odontogenic sources of DNM remained relatively constant across the study periods, the proportion of pharyngeal, laryngeal, and tonsillar origins showed a decreasing trend. According to Prado-Calleros et al. (5), there is variability among reports regarding the most frequent source of infection; therefore, it is difficult to definitively establish a single predominant origin. In some studies, the term “cervical” includes pharyngeal, laryngeal, and tonsillar infections, which further complicates accurate classification and comparison. These apparent temporal changes should be interpreted cautiously, as historical variability in terminology, particularly the use of ‘cervical’ as a composite category, limits direct comparison across decades. In any case, DNM should be recognized as a lethal infection originating from the oral cavity and the head and neck region, extending into the mediastinum.

Fascial planes and anatomical conduits

The deep cervical fascia consists of multiple layers that create spaces for infection to descend into the thoracic cavity (29-31). Three principal anatomical corridors have been described as routes for mediastinal spread in DNM (32,33):

• Pretracheal space: located anterior to the trachea, extending caudally from the thyroid gland into the superior mediastinum. It represents the most common pathway of anterior extension and anatomically corresponds to Type I and Type IIA in the Sugio and Okamoto classification.
• Visceral-vascular space (carotid Sheath): enclosing the carotid artery, internal jugular vein, and vagus nerve, which facilitates infection tracking along the vascular and airway structures into the middle mediastinum.

Retrovisceral space: situated between the alar fascia and the prevertebral fascia, this space corresponds to the posterior component of the retropharyngeal and danger space continuum commonly described in anatomical literature. It extends from the skull base into the mediastinum and continues caudally along the prevertebral fascia beyond the diaphragm. Laterally, it is bounded by the fusion of the alar fascia with the carotid sheath and paravertebral fascia and represents a principal pathway for posterior mediastinal dissemination. It is the principal pathway for posterior mediastinal dissemination and is particularly associated with the recently proposed Type IIC variants (13).

Clinical implications

Posterior mediastinal spread, particularly through the retrovisceral space, is often underrecognized in the early stages of DNM. Accurate identification is essential, because infections confined to the posterior mediastinum (Type IIC) may be often unsuitable for conventional anterior or transcervical surgical drainage (13). In such cases, video-assisted thoracoscopic surgery (VATS) or hybrid drainage approaches may be required to achieve adequate source control. DNM poses a formidable diagnostic challenge owing to its rarity, nonspecific early presentation, and fulminant clinical course. Prompt recognition is imperative, because diagnostic delay is strongly associated with systemic deterioration, multiorgan failure, and increased mortality (26). This section reviews the established diagnostic criteria, evaluates the current imaging modalities and their limitations, and underscores the specific diagnostic challenges presented by isolated posterior mediastinal involvement, particularly in Type IIC disease (13,34,35).

Historical framework: Estrera’s diagnostic criteria

In 1983, Estrera et al. (36) proposed four diagnostic criteria, in which computed tomography was used to identify the spread of infection (5,30,37,38). These criteria remain a foundational reference for diagnosing DNM:

• Clinical evidence of severe oropharyngeal infections;
• Characteristic roentgenographic features of mediastinitis;
• Documentation of necrotizing mediastinal infections during surgery;
• Establishment of the relationship between oropharyngeal infection or cervical infection and the development of a necrotizing mediastinal process.

While these criteria provide a structured approach, they must be interpreted in the context of modern imaging capabilities and multidisciplinary clinical assessment to ensure timely and accurate diagnosis.

Classification based on the type of mediastinal extension

The classification of DNM based on the type of mediastinal extension is crucial for guiding appropriate surgical intervention (8,39,40), facilitating effective interprofessional communication, and predicting clinical outcomes. Among the classification systems proposed over the past two decades, that introduced by Endo et al. in 1999 was the most widely adopted (12). However, increasing clinical experience and advances in high-resolution imaging have revealed the important limitations of Endo’s classification, particularly in cases involving the posterior mediastinal space. These observations have led to the recent proposal of a refined subclassification, termed Type IIC, which has significant implications for diagnostic evaluation and surgical planning (13).

Regarding mediastinal routes of infection, Endo et al. proposed a disease classification system (12) that stratifies DNM into three categories:

• Type I: infection confined to the upper mediastinum above the carina;
• Type IIA: infection extending into the lower anterior mediastinum;
• Type IIB: infection involving both the anterior and posterior compartments of the lower mediastinum (LM).

Sugio and Okamoto et al. (13) analyzed the distribution of Endo’s classification subtypes across different decades. From 1999 to 2009, the proportions of Type I, Type IIA, and Type IIB were 28.3%, 13.3%, and 58.3%, respectively, in the 2010s, the corresponding proportions were 37.1%, 25.6%, and 37.1%, respectively; and in the 2020s, the proportions were 53.2%, 21.5%, and 25.2%, respectively (Table 3). The increasing proportion of Type I cases in recent years suggests that DNM is being diagnosed at an earlier stage of disease progression. This observation is likely attributable to earlier imaging-based detection—particularly the routine use of contrast-enhanced CT in severe DNIs—rather than reflecting any substantive change in the underlying pathophysiology of DNM.

Despite its utility, Endo’s classification lacks the specificity to distinguish infections confined exclusively to the posterior mediastinum. Clinical experience indicates that a significant proportion of cases currently categorized as Type IIB exhibit no anterior mediastinal involvement (12,13). Therefore, this limitation within the current framework may lead to suboptimal surgical access, inadequate drainage, and an increased risk of postoperative complications.

To address this gap, Sugio and Okamoto et al. conducted a nationwide multicenter retrospective study including institution for head and neck surgery and thoracic surgery, involving 225 Japanese patients with DNM (13), which was defined by the criteria of Estrera et al. (36). Based on radiologic and surgical findings, they proposed the following new classification system:

• Type I: infection limited to the area superior to the carina level;
• Type II: spreading to the LM;
• Type IIA: infection limited to the anterior LM;
• Type IIB: infection spread to both the anterior and posterior LM;
• Type IIC: infection limited to the posterior LM.

In total, 225 patients were assessed for the extent of mediastinal infection. Among them, 100 were classified as Type I (44.4%), 20 as Type IIA (8.9%), 62 as Type IIB (27.6%), and 43 as Type IIC (19.1%). Regarding cervical infection, the retrovisceral space was the most frequently involved site (n=137, 60.9%). The frequency of spread through the pretracheal and vascular visceral spaces was 49.3% (n=111) and 52.0% (n=117), respectively. The relationship between the route of cervical spread and type of mediastinal extension was also analyzed. Type IIA mediastinal infections more commonly spread through the pretracheal space (70%) than through the retrovisceral space (20%). In contrast, Type IIC infections spread more frequently through the retrovisceral space (88%) than the pretracheal space (26%). Thus, the recognition of the pattern of mediastinal extension has important implications for both the diagnosis and treatment planning.

Following the publication of the new classification (13), two subsequent studies reported cases that were classified according to the revised system. Among the 271 cases included in these three reports, the proportions of Type I, Type IIA, Type IIB and Type IIC were 43.5%, 11.4%, 26.5%, and 18.4%, respectively (Table 3).

Surgical management

The management of DNM fundamentally relies on a multidisciplinary strategy that incorporates timely surgical drainage, appropriate antimicrobial therapy, and airway management, such as tracheotomy (41-43). It is essential to support the expertise of thoracic surgery, otolaryngology, infectious disease, and critical care teams (44-47). Once DNM is confirmed, initial management should follow established sepsis principles in critically ill patients, including airway protection, adequate oxygenation, hemodynamic resuscitation/support, prompt antimicrobial therapy, and definitive source control. As DNM most commonly arises from an oropharyngeal focus with progression through DNI prior to mediastinal extension, impending airway compromise is a frequent and clinically significant concern. The role of routine tracheostomy in DNM remains controversial; nevertheless, some authors advocate tracheostomy at the index operation for all patients, given the anticipated need for prolonged invasive mechanical ventilation and the risk of upper airway obstruction due to postoperative pharyngeal edema (32). Empiric broad-spectrum intravenous antibiotics are typically initiated as first-line therapy and subsequently de-escalated or tailored based on culture results from surgically drained specimens. Common empiric regimens providing aerobic and anaerobic coverage include piperacillin–tazobactam or a second- or third-generation cephalosporin in combination with metronidazole or clindamycin for anaerobic coverage (3). Among these components, this section focuses specifically on surgical drainage, which is a pivotal intervention. Surgical drainage is indispensable to achieve life-saving source control in patients with DNM (35,42,48,49). The foundation of surgical treatment for DNM is the essential and comprehensive drainage of the infected spaces, beginning with mandatory cervical incision and drainage to secure adequate source control at the level of the neck (50-54). If adequate drainage cannot be achieved and septic shock persists or worsens, reassessment of cervical and mediastinal infection is warranted; prompt re-exploration should be undertaken when persistent or progressive infection is identified. The optimal surgical approach to the thoracic mediastinum, however, remains controversial, with options for thoracic drainage including transcervical, posterolateral thoracotomy, transsternal, subxiphoid and video-assisted thoracoscopic approaches (47,55-62). Sugio and Okamoto et al. (13) showed that Type I was most often managed with VATS/endoscopic drainage (34.0%) or transcervical drainage (31.0%); Type IIA with VATS (40.0%) or thoracotomy (40.0%); Type IIB with thoracotomy (43.6%) or VATS (41.9%) (transcervical drainage 11.3%); and Type IIC with VATS (41.9%), transcervical drainage (34.9%), or thoracotomy (20.9%).

For cases extending into the LM, the surgical paradigm has undergone significant evolution over the past three decades. Prior to the 1990s, mediastinal extension was typically managed using transcervical approaches alone, a strategy historically associated with unacceptably high mortality (63,64). In a retrospective review from 1997, Corsten et al. (65) reported a 47% mortality rate with transcervical drainage alone and a 19% mortality rate with thoracic mediastinal drainage, compared with previously reported rates exceeding 40% with transcervical drainage alone. Thoracotomy was established as the standard of care for lower mediastinal involvement throughout the 1990s (56,66-68). One potential disadvantage of posterolateral thoracotomy for mediastinal drainage is the lack of access to the contralateral hemithorax, which presents challenges in patients with extensive bilateral abscess lesions. An early adaptation to this limitation, described by Ris et al. (47), is clamshell incision. This approach offers a wide surgical field with access to the bilateral hemithoraces for extensive exploration and drainage. However, it is now rarely required. With the advent and refinement of minimally invasive techniques in the 2000s, VATS has emerged as a less invasive yet equally effective alternative to thoracotomy (6,59,69-73). Mediastinal VATS drainage was first proposed by Roberts et al. (59) in 1997, and highlighted the possibility of achieving sufficient drainage with the decreased morbidity of a minimally invasive approach.

In a nationwide multicenter Japanese study of 225 patients (13), Tanaka et al. (74) analyzed the data of 141 patients treated between 2012 and 2016. They reported 90-day mortality rates of 4.8% (4/83) in the VATS group and 8.6% (5/58) in the open thoracotomy group (P=0.87), thereby confirming the safety and efficacy of VATS. The re-operation rates also did not differ significantly, being 24.1% (20/83) in the VATS group compared to 15.5% (9/58) in the thoracotomy group. Furthermore, there was no marked difference in post-operative outcomes, including the volume of blood loss, length of hospital stay, duration of mediastinal drainage, or rates or duration of mechanical ventilation. However, this study is limited by the small sample sizes and retrospective design. In another study by Leonardi et al. (75), no statistically significant differences were observed between the VATS group (n=6) and the thoracotomy group (n=15) in terms of postoperative complication rates and mortality. However, the VATS group showed notable advantages, including a significantly shorter mean operative time (215 vs. 250 min, P=0.02) and reduced mean duration of intensive care unit (ICU) stay (12 vs. 16 days, P=0.03). These results highlight the favorable outcomes associated with VATS, not only reducing surgical trauma and shorter recovery times but also its emerging role as the preferred approach, especially for patients with posterior mediastinal involvement.

Of particular importance is the recently identified Type IIC variant, which is characterized by infection limited to the posterior LM. Anatomically, the infection is located posterior to the esophagus and anterior to the vertebral column, an area not adequately visualized or drained through the anterior thoracic incisions. Posterior VATS, therefore, offers an optimal, minimally invasive approach for effective drainage (13). The incorporation of Type IIC into the DNM classification system represents a clinically meaningful refinement that integrates radiologic, anatomic, and surgical considerations (13,34,75). This modification has the potential to improve diagnostic accuracy, guide individualized surgical strategies, and ultimately improve patient outcomes.

The prognosis

Traditionally, DNM has been associated with a prohibitively high mortality rate, with early reports citing figures approaching 40%. Over the past several decades advances in diagnostic imaging, antimicrobial therapy (3,26,67), surgical techniques, and intensive care have markedly improved survival rates (8,30,67,73). In our literature analysis of 60 articles (Table S1 and Table 4), the mortality rates demonstrated a consistent decline across successive decades. The mortality rate decreased from 24.7% (44/178) in 2000–2009 to 14.1% (183/1,296) in 2020–2025. The larger case volume in more recent decades may make the descriptive mortality proportions more stable within the included series/registry cohorts. The reoperation rate also decreased from 40.5% (51/126) during 2000–2009 to 36.5% (324/886), although the difference was relatively small. These decade-specific proportions are descriptive summaries of the included reports and should not be interpreted as precise population-level estimates. This progressive downward trend underscores substantial improvements in clinical practice and patient outcomes (5,76-78). Several factors are likely to have contributed to these gains. Refinements in operative techniques and mediastinal drainage strategies have reduced the need for reintervention; however, timely and appropriate re-drainage remains important for improving the prognosis. Improvements in perioperative care, including advances in critical care, optimized infection control with broad-spectrum antimicrobials, and modern respiratory management, have further reduced mortality. In addition, the substantial increase in case volume in the most recent decade has facilitated the accumulation of surgical expertise, which may have translated into an improved overall prognosis.

Data from the Japanese Association for Thoracic Surgery (6), encompassing 1,677 cases over 4 time periods, demonstrated an overall 30-day mortality of 4.6% and a hospital mortality of 7.7% (Table 5). Both 30-day and hospital mortality rates remained relatively stable across the periods (4.4–5.3% and 7.0–9.0%, respectively). Mortality rates for DNM in Japan remain comparatively low, likely reflecting the benefits of an early diagnosis, standardized critical care, and advances in surgical and perioperative management. Sugio and Okamoto et al. identified advanced age and extension of infection to the LM (Type II disease) as significant prognostic factors for DNM (13,77). In their logistic regression model, mediastinal involvement extending below the carina was independently associated with an increased 90-day mortality (odds ratio 4.63; P=0.03). Similarly, in the Cox proportional hazards model for the overall survival, increasing age was significantly correlated with worse outcomes [hazard ratio (HR) 1.04 per 1-year increase; P=0.03]. These findings suggest that both patient age and the anatomical extent of infection play critical roles in determining the prognosis, underscoring the importance of early recognition and tailored surgical intervention in high-risk patients, such as those with diabetes. Notably, no statistically significant differences in the prognosis were observed among Type IIA, Type IIB, and Type IIC (13). Sugio and Okamoto et al. (13) showed that Type IIC tended to have more favorable outcomes than Type IIA/IIB (lower 90-day mortality: OR 0.21 vs. Type IIA and OR 0.19 vs. Type IIB; and improved overall survival vs. Type IIB: HR 0.54). However, none of these comparisons reached statistical significance [all P>0.05 with wide 95% confidence intervals (CIs)], likely reflecting limited statistical power due to sample size.

Chen et al. (14) reported that among 181 patients with DNM, 39 died of the disease, corresponding to a mortality rate of 21.6%. Their analysis further identified age ≥55 years old, Endo’s classification Type IIB on computed tomography, septic shock, and elevated C-reactive protein levels at admission as independent predictors of mortality. Of particular importance, Endo Type IIB represents infection extending into both the anterior and posterior compartments of the LM, a pattern that often necessitates invasive surgical interventions such as thoracotomy. Accordingly, Chen et al. concluded that Endo Type IIB serves as a robust prognostic marker of disease severity, reflecting not only the heightened surgical complexity but also the broader extent of infectious dissemination, which predisposes patients to a pronounced systemic inflammatory response and a markedly increased risk of septic shock (14). Similarly, Zhao et al. (15) reported that among 31 patients with DNM, 8 deaths occurred within 30 days, yielding a 30-day mortality rate of 25.8%. Notably, patients categorized as having Endo Type IIB exhibited disproportionately higher mortality, underscoring the adverse prognostic implications of combined anterior and posterior mediastinal involvement. Taken together, these findings indicate that classifying the extent of mediastinal involvement based on the anatomical spread of infection is a critical factor for assessing the disease severity and prognosis.

Limitations

This narrative review had several limitations. Most included reports were retrospective and of variable methodological quality, introducing potential bias. Some degree of patient overlap between cohorts and registry-based reports is possible, and the overall proportions should therefore be interpreted as descriptive approximations. We did not perform a formal risk-of-bias assessment, and all evidence was observational, limiting causal inference regarding specific surgical strategies. Although screening and data extraction were conducted independently by two reviewers to minimize selection and extraction bias, only aggregate data were available, precluding adjusted patient-level analyses for confounders. However, given the rarity of this condition and the potentially fatal consequences of delayed treatment, prospective studies are often impractical or ethically unfeasible. Despite these limitations, we believe that prompt diagnosis and timely surgical intervention, as highlighted in this review, are critical to improving patient outcomes.

Conclusions

Our investigation indicates that early detection through advanced imaging, appropriate antimicrobial therapy, and timely surgical intervention has markedly improved outcomes in DNM. Type II disease remains a critical determinant of the prognosis, underscoring the importance of precise assessment of mediastinal extent and anatomically tailored drainage. Future international validation of the revised classification, including Type IIC, is particularly essential to refine the prognostic stratification and optimize therapeutic strategies.

Acknowledgments

We thank Dr. Brian Quinn (JMC) for critical comments in preparing this manuscript.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://med.amegroups.com/article/view/10.21037/med-2025-1-46/rc

Peer Review File: Available at https://med.amegroups.com/article/view/10.21037/med-2025-1-46/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-2025-1-46/coif). The authors have no conflicts of interest to declare.

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