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Updated: Dec 7 2021

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
  • Etiology
    • 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
        • other infectious causes
          • dental infections - progress to involve the submandibular space then the mediastinum
            • acute necrotizing ulcerative gingivitis (trench mouth)
              • treatment
                • antibiotics
                • chlorhexidine mouthwash
                • regular dental care
      • 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
  • 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
  • Prognosis
    • Survival with treatment
      • 40% acute mortality rate with treatment
      • 10-year survival rate is 40%
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