Mediastinitis


Mediastinitis

Description, Causes and Risk Factors:

Mediastinitis is an infection affecting the mediastinum. It can be a life-threatening condition and requires urgent surgical and medical intervention. Mediastinitis may be due to:

    Infection originating from structures within the mediastinum.

  • Infection descending from the oropharynx through the fascial planes in the neck (e.g. the carotid space, the prevertebral space). This descending infection is known as descending necrotising mediastinitis.

  • A rare fibrotic reaction to granulomatous diseases such as histoplasmosis. This is known as fibrosing mediastinitis.

Mediastinitis is usually results from an infection. It may occur suddenly (acute) or may develop slowly and get worse over time (chronic). It most often occurs in patients who recently had an upper endoscopy or chest surgery.

Other causes of mediastinitis include:

    Anthrax inhalation.

  • Cancer.

  • Histoplasmosis.

  • Radiation.

  • Sarcoidosis.

  • Tuberculosis.

Risk factors include:

    Disease of the esophagus.

  • Problems in the upper gastrointestinal tract.

  • Recent chest surgery or endoscopy.

  • Weakened immune system.

Mediastinitis appears to be a disease of young men with a mean age in the mid fourth decade of life. Most persons with mediastinitis are in their third to fifth decades of life; however, case reports have documented mediastinitis in patients as young as 2 months and as old as the eighth decade.

Symptoms:

Symptoms may include:

    Fever and/or rigors can occur.

  • Shortness of breath may be present.

  • Retrosternal chest pain, usually described as pleuritic, may radiate to the neck or back.

  • There may be a sensation of soreness or congestion in the neck if the condition is due to descending infection.

  • The patient may notice that their neck is swollen.

  • Confusion or disorientation may be present due to the onset of systemic sepsis.

  • There may be evidence of sternal wound infection and sternal instability post-cardiothoracic surgery.

Signs may include:

    The patient can be systemically unwell and shocked.

  • Fever may be evident.

  • Edema and/or erythema of the neck and face may be found.

  • There may be crepitus of the skin of the chest and neck due to surgical emphysema.

  • The mouth should be examined for evidence of pharyngeal infection or foreign bodies.

  • Localized or diffuse swelling of the neck may be seen.

  • Cranial nerve deficits may occur.

  • Auscultation of the heart may reveal a crunching sound.1

Diagnosis:

The diagnosis of mediastinitis is often a clinical one. No single laboratory investigation can confirm the diagnosis; however, studies that may help in the diagnosis of mediastinitis include the following:

    WBC count may be significantly elevated.

  • Electrolytes and glucose measurements may reveal anion gap or indication of underlying diabetes.

  • Blood cultures

  • Swab from any site of infection

It is important to notify the laboratory of the possible presence of anaerobic organisms and the strong possibility of mixed growth.

    Many laboratories routinely report only a single predominant organism.

  • Close coordination with the laboratory is vital to optimize the antibiotic regimen.

Tests include:

    Chest CT scan or MRI scan.

  • Chest x-ray.

Your health care provider may insert a needle into the area of inflammation and remove a sample to send for gram stain and culture to determine the type of infection.

Treatment:

Mediastinitis may result in airway compromise. Protection of the airway is vital. Since patients may present in septic shock, adequate volume resuscitation is essential. Ensure an adequate airway.

    Do not allow a patient who is potentially unstable to be placed into the CT scanner without ensuring that the airway is adequately protected.

  • Intubation may be difficult because of soft tissue swelling. Fiberoptic assistance may be required and the patient may need an emergent cricothyrotomy or tracheostomy.

  • In addition to the usual complications of intubation, it may be further complicated by trauma to the retropharyngeal wall, laryngospasm, or aspiration of purulent material.

  • Antibiotic therapy should be initiated without delay.

  • Fluid resuscitation and management of sepsis are essential.

Surgical Options:

    Extensive and aggressive debridement of necrotic tissues with exploration of all mediastinal fascial spaces may be required.

  • Controversy exists about whether the cervical approach or the transthoracic approach is best. Some physicians support a combination of the two approaches. In some case series, the combination approach has been associated with a lower mortality rate.

  • Depending upon the resources available, consultations may include otorhinolaryngology, cardiothoracic surgery, and general surgery.

  • The necessity for extensive drainage may mandate the transfer of some patients to a tertiary referral center.

NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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