甲状腺切除术后下行坏死性纵隔炎

文献信息

中文摘要

背景： 甲状腺切除术是常用的内分泌手术，并发症发生率总体较低。下行坏死性纵隔炎（DNM）是一种极为罕见但危及生命的并发症，由颈部感染向纵隔扩散所致。甲状腺手术后发生DNM仅见罕见报道。
方法： 我们回顾性分析了两家三级中心2023年至2025年间甲状腺手术后发生DNM的5例患者。回顾了患者的人口学资料、合并症、手术方式、临床表现、影像学、微生物学、治疗、并发症和结局。诊断基于颈纵隔感染的临床和影像学证据，并在4例接受手术引流的患者中获得术中确认。使用PubMed、MEDLINE和Embase进行了文献复习。
结果： 该病例系列包括4名女性和1名男性（年龄35-68岁，平均53.8岁）。所有患者均至少有一种合并症，包括肥胖、心血管或呼吸系统疾病、免疫受损和慢性尼古丁使用。手术方式包括全甲状腺切除术（n=3）和甲状腺次全切除术（n=2）。症状在术后2-10天出现，包括颈部疼痛、肿胀、发热、吞咽困难、呼吸困难、心动过速和皮下气肿。颈部和胸部增强CT在所有患者中均显示与DNM一致的发现，4例需要手术引流的患者获得术中确认。微生物学分析在3例患者中鉴定出化脓性链球菌，在1例患者中鉴定出肺炎链球菌。1例化脓性链球菌患者同时分离出甲氧西林敏感金黄色葡萄球菌（MSSA），另有1例患者快速A组链球菌试验阳性但无确认性培养。治疗包括颈部引流（n=4）、胸部干预（n=2）、气管修复（n=1）和ICU入住（n=4）。并发症包括急性肾衰竭、感染性休克、胸膜/心包积液、肺栓塞和心脏骤停。所有患者均存活，住院时间7至42天（中位数21天）。尽管所有患者的急性感染过程均消退，但部分患者需要康复治疗，1例出现影响日常活动和工作能力的长期残疾。
结论： 甲状腺切除术后DNM罕见但可能危及生命。早期识别、增强CT、及时手术引流和广谱抗生素至关重要。认识易感因素并进行警惕的术后监测可改善结局。

英文摘要

BACKGROUND: Thyroidectomy is a commonly performed endocrine procedure with generally low complication rates. Descending necrotizing mediastinitis (DNM) is an exceptionally rare but life-threatening complication resulting from cervical infections that spread into the mediastinum. DNM following thyroid surgery has been reported only rarely.
METHODS: We analyzed retrospectively five patients who developed DNM following thyroid surgery between 2023 and 2025 at two tertiary centers. The patients' demographics, comorbidities, surgical procedures, clinical presentation, imaging, microbiology, treatment, complications, and outcomes were reviewed. The diagnosis was based on clinical and radiological evidence of cervicomediastinal infection, with operative confirmation in the four patients who underwent surgical drainage. A literature review was conducted using PubMed, MEDLINE, and Embase.
RESULTS: The case series included four women and one man (age 35-68, mean 53.8 years). All patients had at least one comorbidity, including obesity, cardiovascular or respiratory disease, immune compromise, and chronic nicotine use. Surgical procedures included total thyroidectomy (n = 3) and hemithyroidectomy (n = 2). Symptoms developed 2-10 days postoperatively, including cervical pain, swelling, fever, dysphagia, dyspnea, tachycardia, and subcutaneous emphysema. Contrast-enhanced (CT) of the neck and chest demonstrated findings consistent with DNM in all patients, with operative confirmation in the four patients requiring surgical drainage. Microbiological analyses identified Streptococcus pyogenes in three patients and Streptococcus pneumoniae in one patient. Concomitant methicillin-susceptible Staphylococcus aureus (MSSA) was isolated in one of the patients with S. pyogenes, while an additional patient had a positive rapid Group A Streptococcus test without confirmatory culture. Treatment included cervical drainage (n = 4), thoracic intervention (n = 2), tracheal repair (n = 1), and ICU admission (n = 4). Complications included acute kidney failure, septic shock, pleural/pericardial effusions, pulmonary embolism, and cardiac arrest. All patients survived with hospital stays ranging 7 to 42 days (median 21). Although the acute infectious process resolved in all patients, some required rehabilitation and one experienced long-term disability affecting daily activities and work capacity.
CONCLUSION: DNM after thyroidectomy is rare but potentially life-threatening. Early recognition, contrast-enhanced CT, prompt surgical drainage, and broad-spectrum antibiotics are essential. Awareness of predisposing factors and vigilant postoperative monitoring improves outcomes.