Descending necrotizing mediastinitis (DNM) is a severe, life-threatening infection that requires prompt diagnosis and aggressive surgical intervention. Management is particularly challenging when the condition is complicated by bilateral empyema and perivascular involvement. A 73-year-old woman presented with septic shock several days after experiencing pharyngeal pain. Initial computed tomography revealed a deep neck infection extending into the mediastinum, with bilateral empyema. Despite emergency thoracoscopic drainage, follow-up imaging revealed the progression of the infection along the perivascular spaces. A staged surgical approach culminating in thoracotomy with extensive debridement and pedicled omental flap coverage from the dorsal pulmonary hilum to the periaortic area was used. Although postoperative management was prolonged and required tracheostomy and extended vasopressor support, the patient eventually recovered and was discharged for rehabilitation. This case demonstrates that while initial thoracoscopic drainage may be appropriate for critically ill patients with DNM, the progression of infection along the perivascular spaces may necessitate escalation to open surgical debridement with omental flap coverage. Careful monitoring of disease progression and appropriate modifications of surgical strategies are crucial for successful treatment.
Keywords: descending necrotizing mediastinitis; empyema; mediastinal infection; omental flap; perivascular involvement; staged surgery.
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