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Mediastinitis   by  : Fatma Elbadry
ACUTE MEDIASTINITIS: Typical Clinical Features of Acute Mediastinitis   Clinical Classification of Acute Mediastinitis  Etiologies and Clinical Settings  diagnosis management Complications of acute mediastinitis
ACUTE MEDIASTINITIS Acute mediastinitis is rare and dramatic condition of a fulminating and usually fatal course   Typical Clinical Features of Acute Mediastinitis   . sudden and dramatic onset , with chills, high fever, and prostration.  Patients are restless and irritable,  Tachycardia, tachypnea,  .  severe substernal chest pain, worsened by breathing or  coughing, and unrelieved by opiates. The pain may be referred into the neck and ear if the process involves the superior mediastinum , whereas posterior or inferior mediastinal involvement may cause radicular pain radiating around the chest and pain between the scapulae.
Signs: supraclavicular fullness and tenderness over the sternum or sternoclavicular joints, crepitus and other signs of mediastinal and subcutaneous emphysema may be prominent. Hamman's sign (a crunching sound synchronous with cardiac systole, heard over the anterior thorax) is characteristic but not always present. Later, tracheal deviation, jugular venous distention, and other signs of compression of mediastinal structures may appear .
Clinical Classification of Acute Mediastinitis   Involvement of different mediastinal regions tends to have typical causes:  infection in the superior mediastinum is most often the result of direct extension from neck infection; anterior mediastinal infection is typical after surgery or penetrating wounds to the anterior thorax; and posterior mediastinal abscesses are characteristic for tuberculous or pyogenic spinal infections.
Acute Mediastinitis: Etiologies and Clinical Settings  Perforation of a thoracic viscus    Esophagus      "Spontaneous": forceful vomiting (Boerhaave's syndrome); pneumatic trauma      Direct penetrating trauma      Impacted foreign body      Instrumentation: esophagoscopy; sclerotherapy; esophageal obturator airway      Erosion: carcinoma; necrotizing infection
   Trachea or main bronchi      Direct penetrating trauma      Instrumentation: bronchoscopy; intubation      Foreign body      Erosion of carcinoma
Direct extension of infection from elsewhere    Intrathoracic:   lung; pleura; pericardium; lymph node; paraspinous abscess    Extrathoracic:      From above: retropharyngeal space; odontogenic      From below: pancreatitis Mediastinitis following sternotomy for cardiothoracic surgery "Primary" mediastinal infection: inhalational anthrax
1 :  Mediastinitis Resulting from Visceral Perforation  : Boerhaave's syndrome   refers to esophageal rupture associated with forceful vomiting, classically after overeating  or excessive drinking. It is the most familiar example of acute mediastinitis , In addition to the clinical manifestations described previously,  hematemesis  may be present before the actual rupture, and tends to diminish or stop after rupture occurs. clinical manifestations:  Unilateral or bilateral  hydropneumothorax  is common and quickly progresses to  empyema
The diagnosis of esophageal perforation   ☻ depends on an appropriate degree of clinical suspicion.  ☻ On the  chest roentgenogram ,  ●  the hallmarks are diffuse mediastinal widening  ● presence of air in the mediastinum and elsewhere in soft tissues. ●   Mediastinal air-fluid levels may be seen,  ● pneumothorax or hydropneumothorax may be present.  ☻ CT  can delineate these abnormalities more clearly.
The diagnosis is usually established by contrast studies, endoscopic examination,  although percutaneous mediastinal aspiration, using a subxiphoid approach, is advocated by some as a means of earlier diagnosis ☻ Successful management of frank, uncontained esophageal perforation  : ●   early surgical repair, drainage of the mediastinum and often the pleural space,  ●   administration of appropriate antibiotics, ●   Percutaneous catheter aspiration of mediastinal abscesses, under CT guidance, IF infection is localized and the clinical setting is less urgent
☻ Complications of acute mediastinitis after  : esophageal rupture ●  localized abscess formation, ●   extensive pleural empyema, ●  and persistent esophagocutaneous fistulas.  ●  Mortality reported due to acute mediastinitis after  esophageal rupture has ranged from 10% to 20%to as high as 40% to 50% □ Timing of surgical drainage has been of prime importance in determining the clinical outcome
☻ Other potential iatrogenic causes of  mediastinitis include:  ●   bronchoscopic perforation and migration of indwelling central venous catheters.  ●   use of laser and mechanical endobronchial procedures, in the setting of malignancy with chronic airway colonization or postobstructive pneumonia, add to the likelihood of potential mediastinal complications.  ●   Intravascular catheters may be another source of acute mediastinitis when the catheter tip erodes through the vessel wall into the mediastinum. Instillation of hyperosmotic,   vesicant, or vasoactive substances via these catheters may induce a chemical, rather than an infectious, inflammation
Direct Extension of Infection from Other Sites:   secondary to  : oropharyngeal infection Infection originating in periodontal tissues in the tonsillar region,  or after pharyngeal perforation extend via the prevertebral, visceral, or pretracheal  spaces or in the carotid sheaths although the usual  route is via the retropharyngeal space to the posterior  mediastinum,  •  also named  descending necrotizing mediastinitis ,  is  perhaps the most clinically devastating form of the  disorder .  •  Odontogenic infection is consistently the most  common source of descending necrotizing mediastinitis
infections are mixed with both aerobic and anaerobic organisms   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Routine serial postoperative cervicothoracic CT imaging and aggressive reexploration and drainage guided by these imaging findings appear to reduce the mortality of this condition  Although thoracoscopic and other percutaneous drainage procedures have been described and may be appropriate in selected patients, thorough open drainage and irrigation remain the standard approach. Treatment of descending necrotizing mediastinitis   requires aggressive surgical drainage, usually via a  cervical approach.  thoracic exploration be reserved for cases in which the infection extends below the level of the fourth vertebral body or the tracheal bifurcation .
[object Object],[object Object],[object Object],[object Object],as a complication of vertebral or costal tuberculous  Both gastric and esophageal ulcers have been reported as causes of mediastinitis, sometimes eroding directly into the pericardium.
Mediastinitis after Cardiac Surgery  ,[object Object],[object Object],[object Object],[object Object],[object Object]
risk factors ,[object Object],[object Object],[object Object],[object Object],Perioperative risk factors include   shaving rather than clipping for hair removal, the use of bilateral internal mammary artery grafts, a longer duration of the surgical procedure and of perfusion time,  greater use of cautery or bone wax,
Postoperative risk factors   a low cardiac output state in the early postoperative period, and greater amounts of postoperative bleeding .   ,[object Object],The pathogenesis  of mediastinitis following sternotomy is debated, although most cases appear to result from direct contamination of the mediastinum at the time of operation.
[object Object],[object Object]
Prevention:   ,[object Object],prophylactic antibiotics are widely used in the perioperative management of cardiac surgery patients.  The prophylactic intranasal application of mupirocin ointment has been shown to reduce by 50% the rate of  Staphylococcus aureus  nosocomial infections
[object Object],[object Object],The  bacteriology  of postoperative mediastinitis  In early prosthetic valve endocarditis.  Staphylococcus epidermidis  and  S. aureus  have been the most frequent organisms  Anaerobes and gram-negative bacilli are rare, Candida species and atypical mycobacteria (especially Mycobacterium chelonae and Mycobacterium fortuitum)  are infrequently reported.  Infection with the last two groups tends to be more indolent
[object Object],The  diagnosis is usually made at the time of reexploration  of the sternotomy wound and rests on a heightened clinical suspicion in the appropriate setting.  diagnostic tests   gallium scanning, CT, and ultrasonography. CT is particularly helpful in identifying and discerning soft-tissue swelling, fluid collections, and sternal erosion or dehiscence .
[object Object],therapy  for post-sternotomy mediastinitis consists of early surgical exploration, débridement and drainage, irrigation, and prolonged administration of systemic antibiotics.
" Primary Mediastinitis": Inhalational Anthrax   ,[object Object],inhalational anthrax, or  woolsorter's disease,  is contracted by inhaling  B. anthracis  spores from animal sources. Inhalation of anthrax spores into the distal air spaces is followed by ingestion by alveolar macrophages and transport to the mediastinal lymph nodes. A hemorrhagic mediastinitis rapidly evolves, followed by bacteremia, overwhelming sepsis, and usually death.
[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],Inhalational anthrax has historically been  a devastating  disease even with appropriate treatment  in the bioterrorism outbreak, prompt diagnosis and initiation of antibiotic therapy plus aggressive drainage of mediastinal and pleural collections resulted in survival of 6 of the 10 patients.
thank you

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Mediastinitis

  • 1. Mediastinitis by : Fatma Elbadry
  • 2. ACUTE MEDIASTINITIS: Typical Clinical Features of Acute Mediastinitis Clinical Classification of Acute Mediastinitis Etiologies and Clinical Settings diagnosis management Complications of acute mediastinitis
  • 3. ACUTE MEDIASTINITIS Acute mediastinitis is rare and dramatic condition of a fulminating and usually fatal course Typical Clinical Features of Acute Mediastinitis . sudden and dramatic onset , with chills, high fever, and prostration. Patients are restless and irritable, Tachycardia, tachypnea, . severe substernal chest pain, worsened by breathing or coughing, and unrelieved by opiates. The pain may be referred into the neck and ear if the process involves the superior mediastinum , whereas posterior or inferior mediastinal involvement may cause radicular pain radiating around the chest and pain between the scapulae.
  • 4. Signs: supraclavicular fullness and tenderness over the sternum or sternoclavicular joints, crepitus and other signs of mediastinal and subcutaneous emphysema may be prominent. Hamman's sign (a crunching sound synchronous with cardiac systole, heard over the anterior thorax) is characteristic but not always present. Later, tracheal deviation, jugular venous distention, and other signs of compression of mediastinal structures may appear .
  • 5. Clinical Classification of Acute Mediastinitis Involvement of different mediastinal regions tends to have typical causes: infection in the superior mediastinum is most often the result of direct extension from neck infection; anterior mediastinal infection is typical after surgery or penetrating wounds to the anterior thorax; and posterior mediastinal abscesses are characteristic for tuberculous or pyogenic spinal infections.
  • 6. Acute Mediastinitis: Etiologies and Clinical Settings Perforation of a thoracic viscus    Esophagus      "Spontaneous": forceful vomiting (Boerhaave's syndrome); pneumatic trauma      Direct penetrating trauma      Impacted foreign body      Instrumentation: esophagoscopy; sclerotherapy; esophageal obturator airway      Erosion: carcinoma; necrotizing infection
  • 7.    Trachea or main bronchi      Direct penetrating trauma      Instrumentation: bronchoscopy; intubation      Foreign body      Erosion of carcinoma
  • 8. Direct extension of infection from elsewhere    Intrathoracic: lung; pleura; pericardium; lymph node; paraspinous abscess    Extrathoracic:      From above: retropharyngeal space; odontogenic      From below: pancreatitis Mediastinitis following sternotomy for cardiothoracic surgery "Primary" mediastinal infection: inhalational anthrax
  • 9. 1 : Mediastinitis Resulting from Visceral Perforation : Boerhaave's syndrome refers to esophageal rupture associated with forceful vomiting, classically after overeating or excessive drinking. It is the most familiar example of acute mediastinitis , In addition to the clinical manifestations described previously, hematemesis may be present before the actual rupture, and tends to diminish or stop after rupture occurs. clinical manifestations: Unilateral or bilateral hydropneumothorax is common and quickly progresses to empyema
  • 10. The diagnosis of esophageal perforation ☻ depends on an appropriate degree of clinical suspicion. ☻ On the chest roentgenogram , ● the hallmarks are diffuse mediastinal widening ● presence of air in the mediastinum and elsewhere in soft tissues. ● Mediastinal air-fluid levels may be seen, ● pneumothorax or hydropneumothorax may be present. ☻ CT can delineate these abnormalities more clearly.
  • 11. The diagnosis is usually established by contrast studies, endoscopic examination, although percutaneous mediastinal aspiration, using a subxiphoid approach, is advocated by some as a means of earlier diagnosis ☻ Successful management of frank, uncontained esophageal perforation : ● early surgical repair, drainage of the mediastinum and often the pleural space, ● administration of appropriate antibiotics, ● Percutaneous catheter aspiration of mediastinal abscesses, under CT guidance, IF infection is localized and the clinical setting is less urgent
  • 12. ☻ Complications of acute mediastinitis after : esophageal rupture ● localized abscess formation, ● extensive pleural empyema, ● and persistent esophagocutaneous fistulas. ● Mortality reported due to acute mediastinitis after esophageal rupture has ranged from 10% to 20%to as high as 40% to 50% □ Timing of surgical drainage has been of prime importance in determining the clinical outcome
  • 13. ☻ Other potential iatrogenic causes of mediastinitis include: ● bronchoscopic perforation and migration of indwelling central venous catheters. ● use of laser and mechanical endobronchial procedures, in the setting of malignancy with chronic airway colonization or postobstructive pneumonia, add to the likelihood of potential mediastinal complications. ● Intravascular catheters may be another source of acute mediastinitis when the catheter tip erodes through the vessel wall into the mediastinum. Instillation of hyperosmotic, vesicant, or vasoactive substances via these catheters may induce a chemical, rather than an infectious, inflammation
  • 14. Direct Extension of Infection from Other Sites: secondary to : oropharyngeal infection Infection originating in periodontal tissues in the tonsillar region, or after pharyngeal perforation extend via the prevertebral, visceral, or pretracheal spaces or in the carotid sheaths although the usual route is via the retropharyngeal space to the posterior mediastinum, • also named descending necrotizing mediastinitis , is perhaps the most clinically devastating form of the disorder . • Odontogenic infection is consistently the most common source of descending necrotizing mediastinitis
  • 15.
  • 16. Routine serial postoperative cervicothoracic CT imaging and aggressive reexploration and drainage guided by these imaging findings appear to reduce the mortality of this condition Although thoracoscopic and other percutaneous drainage procedures have been described and may be appropriate in selected patients, thorough open drainage and irrigation remain the standard approach. Treatment of descending necrotizing mediastinitis requires aggressive surgical drainage, usually via a cervical approach. thoracic exploration be reserved for cases in which the infection extends below the level of the fourth vertebral body or the tracheal bifurcation .
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