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)
• 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

Disposition

• Admit to ICU

See Also

• Pneumomediastinum
• Thoracic Trauma