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Background: Descending necrotizing mediastinitis (DNM) is an acute life-threatening infection that originates in the oropharyngeal region. It is an uncommon disease with a mortality rate of about 20-40%. This high mortality is mainly attributed to delays in diagnosis and treatment and poor drainage of the mediastinum. We highlight key points that may help reduce mortality., Case Description: We analyze a retrospective case series of seven patients diagnosed with DNM between March 2019 and July 2022 at Hospital de la Santa Creu i Sant Pau. The primary oropharyngeal infection was peritonsillar abscess in three cases and odontogenic abscess in four. All patients showed symptoms of severe cervical infection and symptoms suggestive of mediastinitis. A cervicothoracic computed tomography (CT) scan confirmed the presence of cervical and mediastinal collections and emphysema in all cases. All patients were simultaneously evaluated by the otorhinolaryngology and thoracic surgery teams. Broad-spectrum antibiotic therapy was instituted pending culture. All the patients underwent urgent surgery, consisting of cervicotomy to control the cervical focus and unilateral or bilateral video-assisted thoracoscopic debridement and drain of the pleural cavities and mediastinum. Regarding the outcomes, no patients died, one patient (14.2%) underwent transcervical mediastino-thoracoscopy drainage only. In six patients (85.8%) we performed a combined transcervical and transthoracic approach. Reoperation was required in 3 (43%) cases. The parameter that indicated a poor clinical evolution in these patients was an increase in C-reactive protein and the infection extension on the cervicothoracic CT scan. The follow-up was 30 days from last surgery; there were no losses., Conclusions: Based on our experience, the key points that can help reduce the high mortality associated with DNM are a rapid multidisciplinary assessment and a combined surgical procedure, considering the minimally invasive approach as the first option to drain the pleural cavities and mediastinum., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-23-32/coif). The authors have no conflicts of interest to declare., (2024 Mediastinum. All rights reserved.)

Surgical techniques remain the gold standard to diagnose and staging lung and pleural tumours. Non-invasive techniques have become more accurate but actually they are not enough to plan and evaluating prognosis of lung and pleural tumours. In some cases, we need to explore the pleural cavity and the mediastinal lymph node status to confirm or rule out tumour dissemination. The combination of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy through a single transcervical incision allows the surgeon to widen the range of the exploration and to improve the staging for lung and pleural cancers. VAMLA allows to perform a complete lymphadenectomy of the subcarinal space, the right and pretracheal areas. We consider sampling more safety on the left side to avoid left recurrent nerve injuries. Once this mediastinal tissue is removed, the right mediastinal pleura can be identified and incised. Once mediastinal pleura is opened, a 5 mm 30º thoracoscope is inserted through the video- mediastinoscope into the pleural cavity. It allows to obtain samples of parietal or visceral pleural, pleural fluid or lung nodules if present. In case of left-sided thoracoscopy the access to the left pleural cavity is anterior to the aortic arch as for extended cervical mediastinoscopy. The combination of VAMLA and thoracoscopy is useful to explore the mediastinum and the pleural space from a single incision and in the same surgical setting through the transcervical approach., Competing Interests: Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/med.2019.05.02). The series “Mediastinoscopic Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2019 Mediastinum. All rights reserved.)