Acute mediastinal conditions

Matevž SrpčičDepartment of thoracic surgery

Surgical clinicUniversity Medical Centre Ljubljana

0. Introduction

The mediastinum contains vital structures Disturbances here are vitally dangerous

Causes can be External (accidental or iatrogenic trauma, infection) Internal

Perforation of hollow structures (esophagus, airways) Dilatation/rupture of aorta Enlargement of normally present structures

1. Mediastinitis

By far the most common causes are Esophageal perforation Surgery

Rarely, infection can spread from adjacent areas. Acute necrotizing mediastinitis!

(descending necrotizing mediastinitis)

2.1 Acute necrotizing mediastinitis

Life threatening purulent infectionOrigin in upper neck

Odontogenic (60-70%) Peritonsillar Parapharyngeal

Rapid spread along fascial planes downwards

2.2 Microbiology

Mixed aerobic and anaerobic infection (synergistic action!)

Usual suspects: Prevotella, Peptostreptococcus, Fusobacterium,

Veillonella, Actinomyces, oral Streptococcus, Bacteroides, Staphylococcus aureus, Hemophilus species, Bacteroides melaninogenicus

2.3 Less common causes

trauma to the neck, including neck or mediastinal surgery

cervical lymphadenitis and endotracheal intubation

2.4 Presentation

Patient being treated for a deep cervical infection

Deteriorates despite antibiotic treatment or even cervical drainage procedures.

General signs of sepsis Local neck signs of swelling, edema and pain. Disphagia and dispnoe can develop, but are not

necessary for the diagnosis. 12 hours - 2 weeks after the onset of deep

cervical infection Most commonly within 48 hours

2.5 Estrera criteria

1. Clinical manifestations of severe oropharyngeal infection

2. Demonstration of characteristic radiological features of mediastinitis

3. Documentation of the necrotizing mediastinal infection at operation or postmortem examination or both

4. Establishment of the relationship of oropharyngeal infection with the development of the necrotizing mediastinal process

• Estrera AS, Landay MJ, Grisham JM, et al: Descending necrotizing mediastinitis. Surg Gynecol Obstet 157:545-552, 1983.

2.6 Radiographic investigations

Early CT scan!!!

2.7 Treatment

Antibiotic treatment Empiric (piperacillin/tazobactame or carbapenem) Targeted

Surgical drainage and debridment Cervical drainage ± maxillofacial surgery Thoracotomy?

YES, if involvement below Th4/carina YES

Airway management Tracheostomy?

2.8 Prognosis

Pre-antibiotic age 50% mortalityAntibiotics improved it only slightlyLast two decades 15 to 33%

High index of suspicionEarly diagnosis Prompt and aggressive antibiotic, surgical

and supportive treatment

3. Mediastinal haemorrhage

Trauma Aortic rupture Thoracic procedures

If time permits, CT angiography (localization, even treatment)

Who do we call? Cardiac or thoracic?

Sternotomy or thoracotomy is used for access and therapy is aimed at evacuating the clot and repairing the underlying lesion

4. Superior vena cava syndrome

Historically considered a medical emergency Diagnostic or therapeutic challenge?

Classical presentation of dyspnea (54%), suffusion (54%), cough (29%), and arm or facial swelling (23%)

Onset is most commonly insidious

Causes: thoracic malignancy 95%

Get the diagnosis!

Radiotherapy for NSCLC, chemotherapy for small-cell lung cancer and anticoagulation or thrombolytic therapy for SVC thrombosis