Mediastinitis

Background
  • Inflammation of the mediastinum
    • Commonly caused by esophageal rupture or perforation
    • Infection may be caused by esophageal rupture/perforation or spread of infection from remote site
      • Streptococcus and Bacteroides

Etiology
  • Prior cardiovascular surgery (most common cause)[1]
  • Esophageal rupture (Boerhaave Syndrome)
  • Ludwig Angina
  • Thoracic Trauma
  • Lung infection extension

Clinical Features
  • Fever
  • Dyspnea
  • Chest pain
  • Neck pain and swelling
    • Crepitus
  • Signs of Sepsis
  • Hamman sign on auscultation of precordium (crunch heard during systole)

Evaluation
  • CXR - often first modality
    • Typically reveals subcutaneous emphysema, widening of the mediastinum and pleural effusions
  • CT with IV contrast if diagnosis in doubt
  • Septic workup to include:
    • CBC
    • Lactic acid
    • Blood cultures (incl gram Stain)
    • Cultures of mediastinal fluid

Management
  • Aggressive airway management
  • Patients with mediastinitis emergently require surgery
    • Consult
      • CT Surgery for repair
      • ENT if upper neck area
      • GI for possible endoscopy
  • Start broad-spectrum antibiotics to include Pseudomonal coverage[2]

Disposition
  • Admit to ICU

See Also

References
  1. Infections of the mediastinum. SB - Thorac Surg Clin 2009 Feb; PMID 19288819
  2. El Oakley, RM et al. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 1996. PMID 8619682
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