Clinical Study

Ear, Nose & Throat Journal

2022, Vol. 0(0) 1–8
Management of Descending Necrotizing © The Author(s) 2022
Article reuse guidelines:
Mediastinitis, a Severe Complication of Deep sagepub.com/journals-permissions
DOI: 10.1177/01455613211068575
journals.sagepub.com/home/ear
Neck Infection, Based on Multidisciplinary
Approaches and Departmental
Co-Ordination

Chia-Ying Ho, MD1,2, Shy-Chyi Chin, MD2,3, and Shih-Lung Chen, MD2,4 

Abstract
Objectives: Descending necrotizing mediastinitis (DNM) developing after deep neck infection (DNI) is a potentially lethal disease
of the mediastinum with a mortality rate as high as 40% prior to the 1990s. No standard treatment protocol is available. Here, we
present the outcomes of our multidisciplinary approaches for treating DNM originating from a DNI. Methods: Between June 2016
and July 2021, there were 390 patients with DNIs admitting to our tertiary hospital. A total 21 patients with DNIs complicated with
DNM were enrolled. The multidisciplinary approaches included establishment of airway security, appropriate surgery and anti-
biotics, extracorporeal membrane oxygenation, and intensive care unit management. The clinical variables were analyzed. Results:
Two patients died and 19 survived (mortality 9.5%). The patients who died had a higher mean C-reactive protein (CRP) level than did
those who survived (420.0 ± 110.3 vs 221.8 ± 100.6 mg/L) (P = .038). The most common pathogens were Streptococcus constellatus
and Streptococcus anginosus. From 2001 to 2021, the average mortality rate of studies enrolling more than 10 patients was 16.1%.
Conclusion: Multidisciplinary approaches, early comprehensive medical treatment, and co-ordination among departments sig-
nificantly reduce mortality. Patients with severe inflammation and high CRP levels require intensive and aggressive interventions.

Keywords
descending necrotizing mediastinitis, deep neck infection, surgical drainage, tracheostomy, mortality

Introduction describe our multidisciplinary approaches toward treatment of

DNM arising from a DNI.
Descending necrotizing mediastinitis (DNM) is a severe-to-fatal
infectious disease of the mediastinum in which a deep neck
1
infection (DNI) spreads along the cervical fascia and the neck Division of Chinese Internal Medicine, Center for Traditional Chinese
spaces and then down to the mediastinum.1-3 DNM is often Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
2
School of Medicine, Chang Gung University, Taoyuan, Taiwan
fatal; this is usually a complication of an odontogenic in- 3
Department of Medical Imaging and Intervention, Chang Gung Memorial
fection or a peritonsillar abscess.4-6 Management is difficult, Hospital, Linkou, Taiwan
with delayed diagnosis and incomplete mediastinal drainage 4
Department of Otorhinolaryngology and Head and Neck Surgery, Chang
causing most deaths.7,8 The mortality rate was as high as Gung Memorial Hospital, Linkou, Taiwan
40% prior to the 1990s.3,9 No standard treatment protocol has Received: September 29, 2021; revised: November 24, 2021; accepted:
yet been established because the causes and locations of December 6, 2021
infection vary widely.10
Corresponding Author:
However, based on our experience and reports published Shih-Lung Chen, Chang Gung Memorial Hospital Linkou Branch, No. 5, Fu-
over the past 20 years, we considered that the mortality rate Shin Street, Kwei-Shan, Tao-Yuan 33305, Taiwan.
may have fallen. Here, we explore that possibility, and Email: rlong289@gmail.com

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2 Ear, Nose & Throat Journal 0(0)
Materials and Methods
We retrospectively reviewed the medical records of 390 pa-
tients with DNIs and 21 consecutive patients with both DNIs
and DNM admitted to Chang Gung Memorial Hospital,
Linkou, Taiwan, between June 2016 and July 2021. Diag-
nostic imaging based on computed tomography with or
without ultrasonography (US) was performed.
We applied the diagnostic criteria for DNM as (1) clinical
evidence of severe oral/oropharyngeal infection; (2) estab-
lishment of the relationship between DNM and the oral/
oropharyngeal process; (3) characteristic radiographic fea-
tures of mediastinitis.11,12
Treatments included antibiotics, US-guided needle
drainage, and open-surgery incision and drainage. The
broad-spectrum antibiotics ceftriaxon (1 g Q12H) and
metronidazole (500 mg Q8H) were prescribed as empirical
therapy for aerobic and anaerobic bacteria before culture
results were available. The antibiotics were modified based
on the culture data.
The treatment unit included an otorhinolaryngologist, a
thoracic surgeon, a radiologist, an infectious disease
physician, an intensive care unit (ICU) team, and an
anesthesiologist.
We utilized the classification of Endo et al13 for DNM as
Type I: DNM is localized in the upper mediastinum above the
tracheal bifurcation; Type IIA: DNM extends to the lower
anterior mediastinum; Type IIB: DNM extends to the anterior
and lower posterior mediastinum.
Figure 1. The flow chart of management algorithm.
The surgical procedures included tracheostomy and cer-
vical surgery with or without mediastinal drainage performed
by an otorhinolaryngological and/or thoracic surgical team
according to the classification of Endo et al. Repeat surgery
was considered if a residual abscess, necrotic tissue, or un-
satisfactory drainage was evident 2 to 3 days after primary
surgery. If the infection was controlled, and circulatory and/or
respiratory assistance was no longer needed, the patient was
transferred from the ICU to a general ward. The flow chart of
management algorithm was shown as Figure 1.
We recorded the patient age (range 2–86 years), duration of
illness (range 1–14 days), length of hospital stay (range 2–
86 days), intubation period (range 0–26 days), length of ICU
stay (range 0–44 days), white blood cell (WBC) count (range
5200–32900/μL), C-reactive protein (CRP) level (range 2.7–
480 mg/L), blood sugar level (range 103–522 mg/dL), dia-
betes mellitus (DM) status, number of involved deep neck
spaces, US-guided drainage status, surgical incision and
drainage status, tracheostomy and mediastinotomy status, use
of extracorporeal membrane oxygenation (ECMO), morbid-
ities, and mortality. Categorical variables are presented as
proportions and continuous variables as means ± standard
deviations. Specimens for bacterial culture were obtained
during surgery or by drawing blood.
Exclusion Criteria
We identified 28 patients with DNIs complicated by DNM.
However, those with a pneumomediastinum, trauma-related
mediastinal perforations, or a history of head-and-neck cancer
and those who were immunocompromised were excluded.
Finally, 21 patients were enrolled.
Statistical Analysis
All data were analyzed using MedCalc software (ver. 18.6;
MedCalc, Ostend, Belgium). The Kolmogorov–Smirnov test
revealed that the data were not normally distributed. We thus
used Fisher’s exact test to compare categorical variables and
the Mann–Whitney U test to compare continuous variables. A
P-value < .05 was considered to reflect statistical significance.
Results
Demographic and clinical data are listed in Table 1. We en-
rolled 21 patients with DNI and DNM. The 14 males (66.7%)
and 7 females (33.3%) had a mean age of 56.7 ± 22.2 years.
The mean chief complaint and hospital-staying periods were
4.1 ± 3.2 and 28.1 ± 20.0 days, respectively. The mean in-
tubation and ICU-resident periods were 8.0 ± 7.5 and 12.3 ±
12.3 days, respectively. The mean WBC count was 17 057.1 ±
7993.4/μL, the mean CRP level was 239.0 ± 112.5 mg/L, and
the mean blood sugar level was 185.9 ± 112.5 mg/dL.
Thirteen (61.9%) patients had DM. In terms of the num-
ber of involved DNI spaces, no patient (0%) exhibited only 1
Ho et al. 3

Table 1. Clinicopathological characteristics of 21 patients with In terms of treatment, no patient (0%) underwent US-
DNIs complicated with DNM. guided drainage, but 18 (85.7%) required surgical drainage.
Characteristics N (%)
Of these, 5 (23.8%) underwent open surgical incision and
drainage once, 12 (57.1%) underwent such treatment twice, and 1
Total 21 (100.0) (4.8%) underwent such treatment 3 times. Tracheostomy was
Male 14 (66.7) performed for 6 patients (28.5%) and mediastinotomy for 9
Female 7 (33.3) (42.8%). One patient (4.8%) required ECMO during surgery. No
Age, years ±SD 56.7 ± 22.2 intraoperative or immediate postoperative death was recorded.
Chief complaint period, days ±SD 4.1 ± 3.2 In terms of morbidities, pneumonia developed in 7 patients
Hospital-staying period, days ±SD 28.1 ± 20.0 (33.3%), acute kidney injury in 6 (28.5%), septic shock in 6
Intubation period, days ±SD 8.0 ± 7.5 (28.5%), acute liver failure in 3 (14.2%), necrotizing fasciitis
ICU-staying period, days ±SD 12.3 ± 12.3 in 3 (14.2%), and atrial fibrillation in 2 (9.5%). Two patients
WBC, uL ± SD 17057.1 ± 7993.4 died and 19 survived (mortality rate 9.5%).
CRP, mg/L ± SD 239.0 ± 112.5
The survival and mortality groups are compared in Table 2.
Blood sugar, mg/dL ±SD 185.9 ± 112.5
The mortality group exhibited a higher mean CRP level (420.0
Diabetes mellitus 13 (61.9)
± 110.3 mg/L) than did the survival group (221.8 ± 100.6 mg/L)
Deep neck infection space involved 21 (100.0)
(P = .038). No other parametric difference was statistically
Single space 0 (0.0)
Double spaces 5 (23.8) significant. Table 3 lists the pathogens cultured from the 21
Multiple spaces, ≥ 3 16 (76.2) patients with DNI and DNM. S constellatus (nine patients,
Distribution of infectious source 42.8%) was the most common pathogen. Samples from 20
Odontogenic abscess 8 (38.0) (95.3%) patients yielded polymicrobial cultures, whereas no
Peritonsillar abscess 4 (19.1) growth was observed from the sample obtained from 1 patient
Retropharyngeal abscess 4 (19.1) (4.7%). Table 4 lists 22 post-2001 studies that enrolled at least
Unknown 5 (23.8) 10 patients with DNI and DNM. The average mortality rate
Endo et al.’s classification of DNM from 2001 to 2021 based on these 22 studies was 16.1%.
Type I 15 (71.6)
Type IIA 3 (14.2)
Type IIB 3 (14.2) Discussion
Ultrasonography-guided drainage 0 (0.0) Descending necrotizing mediastinitis is a severe soft tissue
Surgical incision and drainage 18 (85.7)
infection of the interpleural spaces and central thoracic or-
Once 5 (23.8)
gans,14 in which an oropharyngeal infection progresses to the
Twice 12 (57.1)
cervical region and spreads along the fascia to the mediasti-
Multiple times, ≥ 3 1 (4.8)
num. The infection exploits the regional anatomical continuity
Tracheostomy performance 6 (28.5)
Mediastinotomy 9 (42.8)
between the cervical spaces and the mediastinum, as well as
ECMO 1 (4.8) the effects of gravity and negative intrathoracic pressure
Morbidity during inspiration.4,15,16 The most fatal form of mediastinal
Pneumonia 7 (33.3) infection is DNM, which was well defined by Estrera et al.
Acute kidney injury 6 (28.5) with the definition later refined by Wheatley et al.11,17,18 The
Septic shock 6 (28.5) DNM rate associated with DNI is 1.7% to 5.4%.19,20 Our rate
Acute liver failure 3 (14.2) was 5.3% (21 of 390 patients). DNI aside, DNM is also caused
Necrotizing fasciitis 3 (14.2) by infection after sternotomy during cardiac operations or
Atrial fibrillation 2 (9.5) esophageal perforations. We explored the clinical manifes-
Mortality 2 (9.5) tations of 21 patients and compared these to those reported
previously, finding that it is critical to deliver appropriate
treatment when patients present with this life-threatening
involved space, 2 involved spaces were recorded for 5 condition.
patients (23.8%), and ≥3 involved spaces were recorded Table 1 shows that male patients predominated (66.7%;
for 16 patients (76.2%). For the distribution of infec- females 33.3%). Most patients were middle-aged (56.7 ±
tious source, there were 8 (38.0) odontogenic abscesses; 22.2 years) as in previous studies.18 CRP, synthesized prin-
4 (19.1) peritonsillar abscesses; 4 (19.1) retropharyngeal cipally by liver hepatocytes, but also by smooth muscle cells,
abscess; 5 (23.8) unknown source. Based on classifica- macrophages, endothelial cells, lymphocytes, and adipocytes,
tion of Endo et al., there were 15 (71.6%) patients as type I; serves as a marker of acute inflammation; the level thereof is
3 (14.2%) patients as type IIA; 3 (14.2%) patients as elevated by pro-inflammatory cytokines.21 Wang et al.22 found
type IIB. that DNI patients with CRP levels >100 mg/L required longer
4 Ear, Nose & Throat Journal 0(0)

Table 2. The comparison between survival group and mortality group.

Characteristics Survival; N (%) Mortality; N (%) P value

Total 19 (100.0) 2 (100.0) .533

Male 12 (63.1) 2 (100.0)
Female 7 (36.9) 0 (0.0)
Age, years ±SD 56.1 ± 22.2 62.5 ± 28.9 .857
Chief complaint period, days ±SD 4.2 ± 3.3 2.5 ± 0.7 .583
Hospital-staying period, days ±SD 27.4 ± 17.9 34.5 ± 45.9 .904
Intubation period, days ±SD 7.7 ± 7.2 10.5 ± 13.4 1.000
ICU-staying period, days ±SD 11.2 ± 10.2 22.5 ± 30.4 .718
WBC, uL ± SD 17 173.6 ± 8351.1 15 950.0 ± 4454.7 .952
CRP, mg/L ± SD 221.8 ± 100.6 420.0 ± 110.3 .038*
Sugar, mg/dL ± SD 178.7 ± 106.4 254.0 ± 197.9 .771
Diabetes mellitus
Yes 12 (63.1) 1 (50.0) 1.000
No 7 (36.9) 1 (50.0)
Deep neck infection space involved
Single space 0 (0.0) 0 (0.0) 1.000
Double spaces 5 (26.3) 0 (0.0) 1.000
Multiple spaces, ≥ 3 14 (73.7) 2 (100.0) 1.000
Ultrasonography-guided drainage
Yes 0 (0.0) 0 (0.0) 1.000
No 19 (100.0) 2 (100.0)
Surgical incision and drainage 16 (84.2) 2 (100.0) 1.000
Once 4 (21.1) 1 (50.0) .428
Twice 12 (63.1) 0 (0.0) .171
Multiple times, ≥ 3 0 (0.0) 1 (50.0) .095
Tracheostomy performance
Yes 5 (26.3) 1 (50.0) .500
No 14 (73.7) 1 (50.0)
Mediastinotomy
Yes 8 (42.1) 1 (50.0) 1.000
No 11 (57.9) 1 (50.0)
ECMO
Yes 1 (5.2) 0 (0.0) 1.000
No 18 (94.8) 2 (100.0)
Morbidity
Pneumonia 6 (31.5) 1 (50.0) 1.000
Acute kidney injury 6 (31.5) 0 (0.0) 1.000
Septic shock 5 (26.3) 1 (50.0) .500
Acute liver failure 3 (15.7) 0 (0.0) 1.000
Necrotizing fasciitis 3 (15.7) 0 (0.0) 1.000
Atrial fibrillation 1 (5.2) 1 (50.0) .185
N, numbers; SD, standard deviation; WBC, white blood cell (normal range: 3500–11000/μL); CRP, C-reactive protein (normal range < 5 mg/L); sugar (normal
range: 70–100 mg/dL); ECMO, extracorporeal membrane oxygenation; *, P < .05. Significant differences are shown in bold

hospital stays (P = .002). The CRP level predicts DNI pro-
gression to DNM. Kimura et al.1 sought clinical predictors of
DNM developing secondarily to DNI; a CRP level ≥30 mg/dL
(thus ≥300 mg/L in the present study) was a risk factor. In-
shinaga et al. found that DNM was associated with a higher
CRP level than was DNI without mediastinitis (P < .005).10
Table 2 shows that in the survival group, the average CRP
level was 221.8 ± 100.6 mg/L, whereas that in the mortality
group was 420.0 ± 110.3 mg/L (P = .038). Therefore, the CRP
level reflects both the severity of inflammation and disease
prognosis.
Descending necrotizing mediastinitis is primarily treated
via airway management, intravenous broad-spectrum antibi-
otics, and surgical drainage of the neck and mediastinum.18
Table 1 shows that most patients underwent surgery (85.7%),
most commonly, two surgeries (57.1%), consistent with the
Ho et al. 5

Table 3. Analysis of pathogens in 21 patients with DNIs data of Inshinaga et al.10 Our patients underwent a mean of 1.5
complicated with DNM. (range 1–3) open surgeries during hospitalization, whereas
Pathogens N (%)
Hsu et al.15 reported a figure of 2.1 (range 1–5). The surgical
treatments included cervical mediastinal drainage without
Aerobic organisms opening of the chest cavity and combined transcervical and
Streptococcus constellatus 9 (42.8) transthoracic mediastinotomy drainage. Several approaches
Streptococcus anginosus 6 (28.5) toward transthoracic mediastinal drainage have been de-
Klebsiella pneumonia 6 (28.5) scribed, including subxiphoid and median sternotomy, pos-
Parvimonas micra 5 (23.8) terolateral thoracotomy, clamshell incision, and video-assisted
Staphylococcus aureus 4 (19.0) thoracic surgery (VATS); however, the optimal treatment
Pseudomonas aeruginosa 4 (19.0) remains unclear.10,15,18,23 Hsu et al. considered that trans-
Acinetobacter baumannii 3 (14.2) cervical mediastinal drainage may be sufficient, especially
Candida albicans 3 (14.2) when a thoracic surgeon is not available15; Yanik et al.4 were
Staphylococcus epidemics 2 (9.5)
of the view that the combination of cervical mediastinal
Escherichia coli 2 (9.5)
drainage and minimally invasive VATS thoracostomy is op-
Enterobacter cloacae 2 (9.5)
timal. However, less-extensive surgical approaches were as-
Stenotrophomonas maltophilia 2 (9.5)
sociated with unsatisfactory outcomes and high re-operation
Staphylococcus hamolytics 1 (4.7)
Anaerobic organisms rates.24 Eighteen of our patients underwent transcervical
Prevotella buccae 6 (28.5) (surgical) open drainage (85.7%), accompanied by transtho-
Prevotella intermedia 4 (19.0) racic mediastinotomy in nine (42.8%).
Prevotella denticola 2 (9.5) Our principles for clinical decisions of the patients un-
Fusobacterium necrophorum 1 (4.7) dergoing surgical drainage twice or multiple times were based
Actinomyces odontolytics 1 (4.7) on the points: After the first surgery, the patient’s clinical
Polymicrobial infectious patients 20 (95.3) condition did not improve, or they had progression of
No growth 1 (4.7) symptoms such as persistent redness and swelling of neck,
hypotension, tachycardia, tachypnea and dyspnea, or the
N = number
followed CT showed no improvement after operations and

Table 4. Studies with at least 10 patients enrolled with DNIs complicated with DNM.

Study Patient Numbers Mean Age, Range (year) Male (%) Mortality (%)

Papalia et al, 2001 13 39.2, 16–67 69.2 23.0

Makeieff et al, 2004 17 40.0, 19–82 94.1 17.6
Inoue et al, 2005 13 59.0, 40–72 61.5 7.6
Iwata et al, 2005 10 53.8, 16–82 70.0 20.0
Sumi et al, 2008 14 62.6a 85.7 7.1
Chen et al, 2008 18 57.8, 16–78 55.5 16.7
Sokouti et al, 2009 13 34.5, 15–56 61.5 23.0
Deu-martin et al, 2010 43 48.0, 18–79 53.4 20.9
Ridder et al, 2010 45 52.1, 4–81 71.1 11.1
Wakahara et al, 2011 11 65.9, 54–78 54.5 0.0
Hsu et al, 2011 29 53.4, 3–82 62.1 10.3
Kocher et al, 2012 17 47.4, 36–76 47.0 5.9
Vural et al, 2012 13 30.0, 11–46 92.3 0.0
Guan et al, 2014 15 46.7, 27–77 80.0 6.6
Dajer-fadel et al, 2014 60 41.2, 18–73 71.7 35.0
Palma et al, 2016 34 46.8, 24–70 76.5 11.8
Hidaka et al, 2017 10 72.4, 47–91 50.0 10.0
Wei et al, 2017 12 56.8, 43–75 83.3 33.3
Yanik et al, 2018 13 48.2, 18–76 76.9 15.3
Dzian et al, 2019 16 48.6, 22–69 68.7 6.2
Ma et al, 2019 16 59.4, 28–79 68.7 18.7
This study, 2021 21 56.7, 2–86 66.7 9.5
a
age range not available.
6 Ear, Nose & Throat Journal 0(0)
Figure 2. In a patient with a DNI and mediastinitis, an abscess
(arrowhead) had compressed the trachea (arrow) back to the level
of the esophagus. The sternal notch is indicated (asterisk).
there were residual or recurrent abscess formation. For such
patients, we performed the surgical drainage again. In addi-
tion, there are several vital organs around mediastinum.
Therefore, the small abscesses caused by DNM were difficult
to drain, which resulted in the need for repeated surgical
drainage. To reduce the times of surgeries and length of
hospital stay, we believe that accurate imaging interpretation
before surgery, appropriate drainage of each abscess, and the
reliable cultures of pathogens cultures are beneficial. Fur-
thermore, choosing the proper antibiotics for targeting specific
cultured pathogens can also shorten the course of treatment.
The extent of DNM was scored as suggested by Endo
et al.13 Surgery seeks to completely drain the abscess, and this
thus dictates the extent of surgery. Transcervical mediastinal
drainage is sufficient if the abscess is limited to the upper part
of the mediastinum (above the tracheal bifurcation) (Endo
type I). However, abscesses of Endo type IIA (extending to the
lower anterior mediastinum) or IIB (extending to the anterior
and lower posterior mediastinum) generally require a sub-
xiphoid approach or midline sternotomy, or posterolateral
thoracotomy, respectively.18 Surgical management must be
tailored to the condition of each patient.
Our tracheostomy rate was 28.5% (Table 1). Tracheostomy
for patients with a DNI and DNM remains controversial.18
Some clinicians consider that tracheostomy is necessary to avoid
difficult intubation and the risk of aspiration, whereas others are
of the view that tracheostomy may increase the risk of con-
tamination of the pretracheal space, act as an source of downward
infectious spread, and aggravate any subsequent mediastinal
infection.17,25 Wolfe et al.26 opined that tracheostomy should not
be routine for patients with a DNI and compromised airway.
We performed tracheostomy when we considered that
intubation might be impossible or prolonged hospitalization
might be required.2,4,18 As shown in Figure 2, one DNI patient
with DNM had an abscess that compressed the trachea back to
the level of the esophagus. We thus performed tracheostomy to
secure the airway.
Table 3 shows that most patients (95.3%) were infected
with several aerobes and anaerobes. No bacterial growth was
observed in only one patient (4.7%), possibly attributable to
isolation failure or the pre-isolation antibiotic regime. The
initial empirical antibiotic treatment for DNM (which we
adopted) is third-generation cefalosporin (ceftriaxon) com-
bined with metronidazole.27 Other broad-spectrum antibiotics
such as ertapenem, carbapenems (imipenem, meropenem),
and/or acylaminopenicilin with a β-lactam inhibitor or
piperacilin/tazobactam can also be given initially if they are
available.9
Pneumonia was the most common morbidity (33.3%),
followed by acute kidney injury (28.5%), septic shock (28.5%),
acute liver failure (14.2%), cervical necrotizing fasciitis
(14.2%), and atrial fibrillation (9.5%). ICU care, morbidity
management, and interventional therapies were all required.
One patient required ECMO because refractory septic shock
developed during surgical drainage. Although the patient sur-
vived, Huang et al.28 reported unsatisfactory ECMO outcomes
for patients with septic shock refractory to medical treatment.
Descending necrotizing mediastinitis is associated with
high rates of mortality. Wheatley et al. reported that the
mortality rate in 1960–1989 was 34.9%, when surgery was
less radical than today.9,17 Kiernan et al29 reported a mortality
rate of 22.9% for the 1990–1998 period. Many studies con-
cluded that the high mortality was attributable to difficulties in
diagnosis and delayed treatment.30
However, as diagnostic methods, surgical techniques,
and ICU protocols improved over time, outcomes and
mortality have also improved over the past 20 years. 2,31
The average mortality rate based on 22 studies was 16.1%.
Deu-Martin et al. found an overall mortality rate (1996–
2006) of 21%. However, when the years were divided into
the 1996–2000 and 2001–2006 periods, the figures dif-
fered dramatically (40% vs 4.3%).32 In 2014, Dajer-Fadel
et al published a 60-patient study reporting a mortality rate
of about 35.0%, but the cited authors focused on DNM below
the tracheal carina, thus the type IIA and IIB conditions as
defined by Endo et al. that cause the most mortality.33 Our
mortality rate was 9.5% (2/21). One patient died of septic
shock, pulmonary hypertension, and multiple organ failure; the
other died of severe pneumonia and septic shock. However,
multidisciplinary approaches afforded favorable results in over
80% of patients.18 Palma et al34 suggested that prompt ICU
admission of patients with severe sepsis, as well as aggressive
surgery, can significantly reduce mortality.
Limitations
Our work had certain limitations. Our patient number was
small; this reduces the power of the evidence. In addition, the
most patients were male. Thus, selection bias was unavoidable.
Ho et al.
Conclusion
Multidisciplinary approaches and early comprehensive
medical treatment significantly reduced mortality caused by
DNM. Patients exhibiting severe inflammation and high CRP
levels require intensive and aggressive intervention.
Acknowledgments
The authors thank all of the members of Department of
Otorhinolaryngology-Head and Neck Surgery, Chang Gung Me-
morial Hospital, Linkou, for their invaluable help.
Author Contributions
Resources: C-YH, S-LC.
Supervision: S-LC.
Writing—original draft: C-YH, S-LC.
Writing—review and editing: C-YH, S-CC, S-LC
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, au-
thorship, and/or publication of this article.
Ethics Statement
This study was approved by the Institutional Review Board (IRB) of
the Chang Gung Medical Foundation (IRB no. 202101172B0). The
data were collected retrospectively, and the patients were anonymized
before data analysis.
ORCID iD
Shih-Lung Chen  https://orcid.org/0000-0003-4051-4009
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