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Mini-Sternotomy for Necrotizing Mediastinitis
Introduction
Descending necrotising mediastinitis secondary to retropharyngeal abscess is rare in adults. Established approaches for surgical drainage are posterolateral thoracotomy, transverse cervicotomy and full median sternotomy.
Presentation
We present a 24 year old man with a one week history of right sided neck pain, sore throat and dysphagia. Nasal endoscopy revealed tonsilitis and intravenous antibiotics were commenced. He deteriorated, developing retrosternal chest pain and systemic sepsis. CT revealed an extensive retropharyngeal abscess descending into the superior mediastinum. The collection was posterior to the sternum, extending around the ascending aorta and lateral to the superior vena cava. Following discussion with the ENT surgeons, an operative plan was devised to drain the collection by a minimally invasive mini-sternotomy incision and undertake tonsillectomy.
Management
A mini-sternotomy was performed, traversing the sternum in the third interspace. This gave excellent access the superior mediastinum. The collection was intra-pericardial and closely related to the ascending aorta, superior vena cava, and innominate vein. The abscess was drained and all infected, necrotic tissue was excised. Following washout, two drains were placed from the supraclavicular region into the mediastinum The manubrium was then closed with sternal wires.
Following 2 weeks of systemic antibiotics the patient made a full and complete recovery.
Discussion

Use of minimally invasive incisions utilised more usually for aortic valve replacement can be effectively employed in the management of descending mediastinal infections and collections to the benefit of the patient, avoiding thoracotomy or full sternotomy.
We describe a novel approach for performing surgical drainage of a mediastinal collection secondary to a retropharyngeal abscess. Mini-sternotomy affords excellent access for drainage and debridement. Use of minimally invasive incisions affords excellent patient satisfaction through low analgesic requirments and speeds hospital discharge without compromising the basic principles of surgery for this often fatal condition.