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Acute mediastinal conditions. Matevž Srpčič Department of thoracic surgery Surgical clinic University Medical Centre Ljubljana. 0. Introduction. The mediastinum contains vital structures Disturbances here are vitally dangerous Causes can be

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acute mediastinal conditions

Acute mediastinal conditions

Matevž Srpčič

Department of thoracic surgery

Surgical clinic

University Medical Centre Ljubljana

0 introduction
0. Introduction
  • The mediastinum contains vital structures
  • Disturbances here are vitally dangerous
  • Causes can be
    • External (accidental or iatrogenic trauma, infection)
    • Internal
      • Perforation of hollow structures (esophagus, airways)
      • Dilatation/rupture of aorta
      • Enlargement of normally present structures
1 mediastinitis
1. Mediastinitis
  • By far the most common causes are
    • Esophageal perforation
    • Surgery
  • Rarely, infection can spread from adjacent areas.
    • Acute necrotizing mediastinitis!

(descending necrotizing mediastinitis)

2 1 acute necrotizing mediastinitis
2.1 Acute necrotizing mediastinitis
  • Life threatening purulent infection
  • Origin in upper neck
    • Odontogenic (60-70%)
    • Peritonsillar
    • Parapharyngeal
  • Rapid spread along fascial planes downwards
2 2 microbiology
2.2 Microbiology
  • Mixed aerobic and anaerobic infection (synergistic action!)
  • Usual suspects:
    • Prevotella, Peptostreptococcus, Fusobacterium, Veillonella, Actinomyces, oral Streptococcus, Bacteroides, Staphylococcus aureus, Hemophilus species, Bacteroides melaninogenicus
2 3 less common causes
2.3 Less common causes
  • trauma to the neck, including neck or mediastinal surgery
  • cervical lymphadenitis and
  • endotracheal intubation
2 4 presentation
2.4 Presentation
  • Patient being treated for a deep cervical infection
  • Deteriorates despite antibiotic treatment or even cervical drainage procedures.
  • General signs of sepsis
  • Local neck signs of swelling, edema and pain.
  • Disphagia and dispnoe can develop, but are not necessary for the diagnosis.
  • 12 hours - 2 weeks after the onset of deep cervical infection
  • Most commonly within 48 hours
2 5 estrera criteria
2.5 Estrera criteria
  • 1. Clinical manifestations of severe oropharyngeal infection
  • 2. Demonstration of characteristic radiological features of mediastinitis
  • 3. Documentation of the necrotizing mediastinal infection at operation or postmortem examination or both
  • 4. Establishment of the relationship of oropharyngeal infection with the development of the necrotizing mediastinal process
        • Estrera AS, Landay MJ, Grisham JM, et al: Descending necrotizing mediastinitis. Surg Gynecol Obstet 157:545-552, 1983.
2 7 treatment
2.7 Treatment
  • Antibiotic treatment
    • Empiric (piperacillin/tazobactame or carbapenem)
    • Targeted
  • Surgical drainage and debridment
    • Cervical drainage ± maxillofacial surgery
    • Thoracotomy?
      • YES, if involvement below Th4/carina
      • YES
  • Airway management
    • Tracheostomy?
2 8 prognosis
2.8 Prognosis
  • Pre-antibiotic age 50% mortality
  • Antibiotics improved it only slightly
  • Last two decades 15 to 33%
  • High index of suspicion
  • Early diagnosis
  • Prompt and aggressive antibiotic, surgical and supportive treatment
3 mediastinal haemorrhage
3. Mediastinal haemorrhage
  • Trauma
  • Aortic rupture
  • Thoracic procedures
  • If time permits, CT angiography (localization, even treatment)
  • Who do we call? Cardiac or thoracic?
  • Sternotomy or thoracotomy is used for access and therapy is aimed at evacuating the clot and repairing the underlying lesion
4 superior vena cava syndrome
4. Superior vena cava syndrome
  • Historically considered a medical emergency
  • Diagnostic or therapeutic challenge?
  • Classical presentation of dyspnea (54%), suffusion (54%), cough (29%), and arm or facial swelling (23%)
  • Onset is most commonly insidious
  • Causes: thoracic malignancy 95%
  • Get the diagnosis!
  • Radiotherapy for NSCLC, chemotherapy for small-cell lung cancer and anticoagulation or thrombolytic therapy for SVC thrombosis