Updated: 12/21/2019

Mediastinitis

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Snapshot
  • A 58-year-old man develops fever, tachycardia, and worsening chest pain 2 days after undergoing a coronary artery bypass surgery for coronary artery disease. On examination, his sternotomy wound is draining purulent fluid. A chest radiograph demonstrates mediastinal widening and a CT scan demonstrates mediastinal gas.
Introduction
  • Clinical definition
    • inflammation of the mediastinum
    • types of mediastinitis
      • acute
        • acute infection often due to complications following a sternotomy
      • chronic
        • fibrosis from chronic inflammatory conditions (e.g., granulomatous disease)
  • Epidemiology
    • incidence
      • 3% incidence of acute mediastinitis following sternotomy
      • very low incidence of chronic mediastinitis
    • risk factors
      • recent sternotomy
  • Pathophysiology
    • mechanism of injury
      • acute
        • contamination from esophageal or retropharyngeal regions 
          • post-surgical
          • esophageal perforation
      • chronic
        • fibrosing inflammation of the mediastinal space in the setting of chronic infection
          • granulomatous diseases
            • tuberculosis
            • sarcoidosis
            • histoplasmosis
    • pathoanatomy
      • normal anatomy
        • superior mediastinum
          • vessels
            • aortic arch
            • superior vena cava
          • nerves
            • vagus nerves
            • phrenic nerves
            • sympathetic trunk
          • other structures
            • thymus
            • trachea
            • esophagus
            • thoracic duct
        • middle mediastinum
          • vessels
            • ascending aorta
            • pulmonary trunk
          • nerves
            • cardiac plexus
            • phrenic nerves
          • other structures
            • heart
        • anterior mediastinum
          • contains no major structures
        • posterior mediastinum
          • vessels
            • descending aorta
            • azygous venous system
          • other structures
            • esophagus
            • thoracic duct
  • Prognosis
    • survival with treatment
      • 40% acute mortality rate with treatment
      • 10-year survival rate is 40%
Presentation
  • Symptoms
    • chest pain
    • fever
    • tachycardia
  • Physical exam
    • purulent discharge from the wound
    • wound erythema
    • sternal tenderness
Imaging
  • Radiographs 
    • indication
      • should be obtained if mediastinitis is suspected
    • findings
      • mediastinal widening
  • Computerized tomography (CT) 
    • indication
      • should be obtained if mediastinitis is suspected
    • findings
      • mediastinal gas and fluid
Differential
  • Acute pericarditis
    • distinguishing factor
      • may present with pleuritic chest pain and a friction rub
  • Cardiac tamponade
    • distinguishing factor
      • may present with Beck triad (hypotension, muffled heart sounds, and jugular venous distension)
Treatment
  • Operative
    • surgical emergency 
      • debridement and broad-spectrum antibiotics  
Complications
  •  Death
 

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