Mediastinitis

Background

• Inflammation of the mediastinum
  • Commonly caused by esophageal rupture or perforation
  • Typically caused by infection
    • Streptococcus and Bacteroides
  • Can be traumatic (swallowed razor blades, etc)

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)

Workup

• Septic workup to include:
  • CBC
  • Blood cultures
  • Gram Stain
  • Cultures of mediastinal pacing wires
• CXR - often first modality
  • Typically reveals subcutaneous emphysema, widening of the mediastinum and pleural effusions
• CT if diagnosis in doubt

Management

• Airway intact?
• 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

See Also

• Pneumomediastinum
• Thoracic Trauma

Sources

Medscape: Mediastinitis Treatment & Managemen. Mueller DK, et al.