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