Descending necrotising mediastinitis: a rare entity in children

We present a case of descending necrotising mediastinitis (DNM) originating from a retropharyngeal abscess in a healthy early childhood patient. The patient had a history of fever, odynophagia and refusal to eat, followed by rapid deterioration of the clinical state. Cervicothoracic CT was performed, which revealed a right parapharyngeal abscess, extending to the mediastinum and occupying the retropharyngeal/visceral space, with gaseous content throughout this collection, associated with bilateral pleural effusion, aspects compatible with DNM. She started broad-spectrum antibiotic therapy and transoral drainage of the parapharyngeal and retropharyngeal collections was performed under general anaesthesia. She was admitted to the intensive care unit. The patient showed clinical, analytical and imaging improvement, having been transferred to the ear, nose and throat department, with favourable evolution. Early diagnosis of DNM by cervicothoracic CT and multidisciplinary approaches, including intensive care, broad-spectrum antibiotics and surgical intervention, are crucial to minimise the morbidity and mortality.

The usefulness of chest drain and epicardial pacing wire culture for diagnosing mediastinitis after open-heart surgery

PURPOSE

Culture of extracted drains or epicardial pacing wires is an easy and noninvasive method for detecting mediastinitis after open-heart surgery, although studies on its sensitivity and specificity are limited. We, therefore, investigated the usefulness of this approach for diagnosing mediastinitis.

METHODS

We retrospectively studied the culture results of drains and epicardial pacing wires extracted from 3308 patients. Prediction models of mediastinitis with and without culture results added to clinical risk factors identified by a logistic regression analysis were compared.

RESULTS

The incidence of mediastinitis requiring surgery was 1.89% (n = 64). Staphylococcus was the causative bacterium in 64.0% of cases. The sensitivity, specificity, and positive and negative predictive values of positive culture results were 50.8%, 91.8%, 10.7%, and 99.0%, respectively. Methicillin-resistant Staphylococcus aureus had the highest positive predictive value (61.5%). A multivariate analysis identified preoperative hemodialysis (OR 5.40 [2.54-11.5], p < 0.01), long operative duration (p < 0.01), postoperative hemodialysis (OR 2.25 [1.01-4.98], p < 0.05), and positive culture result (OR 10.2 [5.88-17.7], p < 0.01) as independent risk factors. The addition of culture results to pre- and postoperative hemodialysis and a lengthy operative time improved the prediction of mediastinitis.

CONCLUSIONS

A culture survey using extracted drains and epicardial pacing wires may provide useful information for diagnosing mediastinitis.

Mimicking descending necrotizing mediastinitis as acute myocardial infarction in a patient with severe coronary artery disease: A case report

RATIONALE

It is a crucial disease that descending necrotizing mediastinitis need to be treated promptly with proper antibiotics and drainage. The characteristics of its symptoms such as chest pain are difficult to distinguish from acute myocardial infarction.

PATIENT CONCERNS

An 80-year-old female presented with severe squeezing chest pain. The cardiac marker was elevated. And coronary angiography showed the significant coronary stenosis. Although the revascularization through percutaneous coronary intervention was completed successfully, the patient still presented chest pain. Computed tomography of neck revealed that hypodense heterogeneous lesions with clear and distinguishable margin extended from the deep neck to mediastinum diffusely.

DIAGNOSES

The patient was diagnosed with descending necrotizing mediastinitis.

INTERVENTIONS

Percutaneous catheter insertion to patient's abscess lesion at was performed.

OUTCOMES

Catheter drainage of descending necrotizing mediastinitis led to an improvement in the patient's condition.

LESSON

Descending necrotizing mediastinitis made chest paint with elevated cardiac enzyme mimicked myocardial infarction.

Pneumonia, pleurisy, mediastinitis, and mediastinal cyst infection secondary to endobronchial ultrasound-guided transbronchial needle aspiration: A case report

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is less commonly used in nonmalignant diseases. In particular, its application in mediastinal cystic lesions has been reported less frequently. EBUS-TBNA is a reassuringly safe procedure with an overall complication rate less than 2%, and serious adverse event rate of 0.14% to 0.16%. The most common complications are infections (mediastinal cyst infection most seen).

PATIENT CONCERNS

A 28-year-old male presented to the hospital with mediastinal cyst that was incidentally discovered by computed tomography. There was no past history of the patient reviewed.

DIAGNOSIS

The cyst was identified as a round, anechoic structure by EBUS and serous fluid was aspirated. The carcino-embryonic antigen, mycobacterium tuberculosis DNA and cultures in the fluid were negative. Cytology analysis showed lots of lymphocytes and no malignant cells. The diagnosis of lymphangioma was confirmed based on the computed tomography and EBUS presentation, the nature of the aspirated fluid and the large number of mature lymphocytes within the cystic fluid.

INTERVENTIONS

Twenty-six hours after EBUS-TBNA, the patient complained of a fever with the highest temperature of 39°C, accompanied by a right-side chest pain, no other symptoms of were reported. The following examinations confirmed the diagnosis of pneumonia, pleurisy, mediastinitis and mediastinal cyst infection, while cultures from cyst and right pleural effusion were both negative. The patient was treated with Teicoplanin+Imipenem/cilastatin, and ultrasound guided transcutaneous catheterization drainage of mediastinal cyst and pleural effusion were performed.

OUTCOMES

Seven days after the treatments, the patient's symptoms resolved, the complete blood count, C-reactive protein, erythrocyte sedimentation rate were lowered. The size of the cyst was slightly reduced on 17 June compared to that before EBUS-TBNA. Although the surgical resection of the cyst was recommended, the patient declined. After extracted the two drainage tubes, the patient was discharged on June 22. The patient was followed up by telephone 6 months after discharge and he remained asymptomatic.

CONCLUSIONS

EBUS-TBNA is a useful diagnostic and therapeutic tool for the management of mediastinal cysts. However, considering the possibility of serious complications, the clinical procedure should be carried out scrupulously with appropriate patient selection and strict aseptic principles.

[Diagnosis and treatment of 12 patients with deep neck infection and inferior mediastinal infection]

Objective:To summarize the clinical manifestations and treatment of patients with deep neck infection with descending mediastinal infection. Methods:The clinical data of 12 patients with deep neck infection with descending mediastinal infection were reviewed. The clinical manifestations, infection origin, bacterial culture results, related systemic diseases, surgical drainage methods and treatment results were analyzed. Results:The typical clinical features of descending mediastinal infection were chest pain and subcutaneous crackling, diagnosis can confirmed by CT scan detected gas and abscess in the neck and mediastinal space. The main origin of infection was pharyngeal infection, followed by odontogenic infection. Systemic diseases were mainly diabetes mellitus. The positive rate of purulent secretion culture was 58.3%（7/12）, streptococcus account for the highest proportion. Surgical treatment included 9 patients undergoing neck surgery alone and 3 patients undergoing combined neck and chest surgery. Chest drainage was performed by thoracic surgery through mediastinoscopy or thoracoscopic surgery or B-ultrasound guided puncture, and no patient underwent open surgery. Ten patients were cured and two died, with a mortality rate of 16.7%. Conclusion:The deep neck infection with descending mediastinal infection has no specificity in the early stage. Timely abscess drainage, effective airway protection, antimicrobial therapy, and management of potentially life-threatening complications such as sepsis, mediastinitis, and pneumonia are the key to successful treatment.

Negative pressure wound therapy for patients with mediastinitis: A meta-analysis

To evaluate clinical effects between conditional treatment and negative pressure wound therapy for mediastinal infection. Multiple databases were searched to identify relevant studies, and the articles that eventually satisfied the criteria were included. All the meta-analyses were conducted with the Review Manager 5.2. To estimate the quality of each article, risk of bias table was performed. Finally, nine studies including 648 patients met the eligibility criteria. The negative pressure wound therapy (NPWT) group and the control group included 353 and 295 patients, respectively. The meta-analysis showed no significant difference in operative time (RR = -6.13, 95%CI [-50.00, 37.74], P = .78; P for heterogeneity <.000001, I2 = 100%). The length of hospital stay (MD = -3.07, 95%CI [-4.38, -1.77], P < .00001; P for heterogeneity = .99, I2 = 0%), re-infection (RR = 0.18, 100%CI [0.08, 0.40], P < .00001; P for heterogeneity = 0.48, I2 = 0%), and mortality were significantly different between the two groups (RR = 0.27, 95%CI [0.12, 0.63], P of overall effect = .002). NPWT is a better therapy than conventional treatment for mediastinitis.

A multidisciplinary approach to the management of descending necrotizing mediastinitis - case series

OBJECTIVES

Descending necrotizing mediastinitis (DNM) is a severe potentially fatal disease of the mediastinum which spreads downwards from oropharyngeal region. Mortality varies from 11 to 40%. There is agreement on the importance of early diagnosis, aggressive surgical treatment and the need for a multidisciplinary approach.

DESIGN

Retrospective study of series of patient treated for DNM regarding multidisciplinary approach and surgical treatment.

PATIENTS AND METHODS

Sixteen patients that were surgically treated for DNM from 2008 to 2017 at our hospital were consecutively enrolled in observational descriptive study.

RESULTS

Twelve patients had disease localised above tracheal bifurcation level. Nine of them underwent transcervical drainage, three patients underwent more extensive treatment. Four patients with disease spread below the treacheal bifurcation level were treated with transcervical drainage in combination with posterolateral thoracotomy or videothoracoscopy. Three patients underwent videothoracoscopy - two of them as primary surgical treatment with need of one reoperation - contralateral videothoracoscopy. The third patient was initially treated with a transcervical approach and videothoracoscopy was indicated as a reoperation because of the progression of the disease. One patient died (mortality 6.25%).

CONCLUSION

In management of descending necrotizing mediastinitis, early diagnosis, aggressive surgical treatment and use of broad-spectrum antibiotics and nowadays also multidisciplinary approach are crucial. Transcervical drainage combined with posterolateral thoracotomy or videothoracoscopy were used with good results.

Deep Neck Infections Are Life Threatening Infections of Dental Origin: a Presentation and Management of Selected Cases

BACKGROUND

Untreated dental caries or even dental manipulations, such as a tooth extraction, might cause direct spread of an odontogenic infection and consequently the development of life-threatening conditions such as deep neck infections (DNI). The most common source of DNI is of odontogenic origin (38.8-49%). Abscess formation or cellulitis can lead to life-threatening complications, despite new diagnostic imaging technology and widespread availability of antibiotics.

OBJECTIVES

To demonstrate the dangers of DNI, which can create life-threatening situations.

METHODS

Five cases of DNI of odontogenic origin, which were referred to the oral and maxillofacial surgery unit, are presented.

RESULTS

Clinical manifestations included trismus, dysphagia, dysphonia, dyspnea, and infection symptoms. In all cases, computed tomography confirmed diagnosis and extent of abscess. Complications included mediastinitis, respiratory distress, osteomyelitis of the jaws, and in rare cases the mandibular condyle. Treatment included securing the airway, immediate surgical drainage, removal of the infection source, and antibiotic therapy. All patients were discharged in stable and improved condition.

CONCLUSIONS

DNI treatment on an emergency basis requires proper diagnosis and effective management. To confirm diagnosis and prevent serious complications, it is essential for physicians to recognize the spaces of the head and neck that are likely to be affected by DNI.

Left colon interposition for esophageal reconstruction after perforation by metal blades ingestion: a case report

Esophageal reconstruction with colonic or jejunal segment is a second choice treatment when the stomach is injured or not adequate for use. These reconstructions, whether pedicled or as free jejunal graft, are technically demanding and they are associated with high rate of morbidity and mortality. Complications are mainly due to insufficient blood supply and therefore anastomotic leak or stricture and graft necrosis. We describe the case of a 51-year-old psychiatric man with diagnosis of esophageal perforation after ingestion of metallic razor blades for suicide intent. The patient was treated at an outside hospital with endoscopic removal of the blades and apposition of endoscopic clips, be cause of esophageal mucosal perforation. Nevertheless, he developed a septic status caused by mediastinitis. The patient underwent several interventions to solve the sepsis and after complete recovery he was referred to our Department for esophageal reconstruction. During surgery we found that the stomach was unavailable for reconstruction, therefore a left colonic interposition pedicled on the left colic vessels was performed through the retrosternal route. During the postoperative course the patient developed acute respiratory failure and suppuration of the cervical wound. The postoperative course was complicated because of the poor compliance of the patient due to his psychiatric disorder. He was discharged in postoperative day (POD) 42 in good clinical conditions, on oral-only diet. Colonic interposition through the retrosternal route after esophagectomy is a technically demanding procedure, associated with high morbidity and mortality, but it is a feasible option when the stomach is not available for reconstruction.

[A Case of Successful Drainage for Mediastinitis during Chemotherapy for Unresectable Advanced Esophageal Cancer]

A 78-year-old man complained of dysphagia. Gastrointestinal endoscopy showed a Type 2 tumor in the lower esophagus and a Type 0-Ⅱa lesion in the posterior wall of the upper gastric body. An enhanced CT scan showed several swollen abdominal and cervical lymph nodes as well as bilateral lung multiple nodules, suggesting distant metastasis. We diagnosed the patient with double cancers consisting of an unresectable advanced esophageal squamous cell carcinoma with multiple lymph nodes and lung metastases(Lt, cT3N4M1, cStage Ⅳb)and early gastric cancer(U, post, cType 0-Ⅱa, cT1N0M0, cStageⅠ). On day 4 of the first course of chemotherapy(docetaxel plus cisplatin plus 5-FU: DCF), a high fever was observed. A chest CT scan revealed suspected mediastinitis and right pyothorax due to perforation by the esophageal cancer. Thoracoscopic mediastinal drainage was immediately performed. CT-guided abscess drainage was added for a residual abscess in the right thoracic cavity on day 10 after drainage surgery. The patient's general condition improved, and he was discharged on 24th postoperative day. The patient was able to reinstitute and continue DCF therapy until disease progression.

Infections of the Neck

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.

[Treatment of Mediastinitis after Open Heart Surgery Using Negative Pressure Wound Therapy with Irrigation]

Mediastinitis occurs after open heart surgery in a small number of cases. When it occurs, early diagnosis and treatment are important. A 69-year-old male patient suffered from mediastinitis after total aortic arch replacement. He has cured completely by negative pressure wound therapy (NPWT) with irrigation method. The vacuum-assisted closure( VAC) method is very useful for wound repair and has recently been used to treat mediastinitis. However, the use of VAC alone does not always result in complete cure. NPWT with irrigation is a very useful infection control method. Performing NPWT before VAC might contribute to improving the outcomes of mediastinitis treatment. However, it is difficult to decide when to switch from NPWT with irrigation to VAC.

Group C strep mediastinitis

This case is significant to the practice of emergency medicine because it represents the development of an uncommon and potentially fatal mediastinal infection from a commonly encountered and appropriately treated community respiratory pathogen. Most published reports on mediastinitis are those that are status-post cardiothoracic surgery. In our report, we discuss a case of a healthy, young individual who developed this morbid entity from extension of a simple respiratory infection where Group C Streptococcus has been isolated as the causative organism, which to our knowledge has not been previously reported. Further, this report outlines how a community acquired pneumonia progressed to a life threatening illness despite proper initial treatment per local and national guidelines.

Should we consider IgG hypogammaglobulinemia a risk factor for severe complications of Ludwig angina?: A case report and review of the literature

RATIONALE

Cervical necrotizing fasciitis (CNF) and descending necrotizing mediastinitis (DNM) are rare forms of complication of Ludwig angina. These potentially lethal infections are difficult to recognize in early stages and are often associated with predisposing factors like diabetes and immunocompromised states. Moreover, IgG hypogammaglobulinemia (hypo-IgG) is considered to be a risk factor of mortality in patients with septic shock; however, it is not routinely quantified in patients with extremely serious infections, particularly in cases with no history or evidence of immunocompromising disorders.

PATIENT CONCERNS

We present a case of a 58-year-old woman who survived Ludwig angina, complicated by CNF and DNM. Despite a rapid diagnosis, aggressive surgical debridement and broad-spectrum antibiotics, the infection and necrosis advanced, requiring multiple surgical interventions and long intensive care unit (ICU) support.

CONCLUSION

We hypothesize that detecting a low level of endogenous IgG and treating with adjuvant passive immunotherapy was key in determining a favorable outcome.

[Prevention and Treatment of Mediastinitis Following Cardiac Surgery]

Mediastinitis after cardiac surgery occurs about 1% of the time and is associated with adverse effects on both short- and long-term outcomes. Therefore, prevention of mediastinitis is very important. However, when this complication occurs, a radical cure should be performed using a safe and reliable method. Many pre-, intra-, and post-operative risk factors have been reported. Perioperative management based on an understanding of the pathological condition that causes this complication is an effective prevention strategy. Early detection and treatment are most important, and there should be close coordination with plastic surgeons. Recently, negative pressure wound therapy has been used widely and appears to be effective for this complication.

Less invasive management of deep neck infection and descending necrotizing mediastinitis: A single-center retrospective study

By a 7-year retrospective review, we reported our experience in management of descending necrotizing mediastinitis (DNM) and deep neck infection (DNI). A retrospective design was used to reveal the clinical characteristics of DNI and DNM. The clinical outcome was analyzed to validate less invasive management. We reviewed 82 patients between 2009 and 2016, 12 of which were diagnosed as DNM by clinical and computed tomography findings. A total of 35 patients had relevant systemic conditions, mainly diabetes mellitus (19 patients). Most cases were secondary to oropharyngeal or dental infections. All patients underwent transcervical drainage, and 10 DNM patients were treated with additional closed thoracic drainage simultaneously. Twenty patients accepted more than 1 operation. Seven patients died as a result of sepsis and/or multiple organ failure. The mortality rate in our study was similar to that in other studies. In our opinion, less invasive therapies are useful to most patients. Transcervical drainage alone is optimal management for all DNI cases and some DNM cases. Additional closed thoracic drainage is enough for type I and IIA DNM with pleural effusion or empyema.

DESCENDING NECROTIZING MEDIASTINITIS SECONDARY TO RETROPHARYNGEAL ABSCESS

Descending necrotizing mediastinitis secondary to a nontraumatic retropharyngeal abscess is very rare. This form of mediastinitis in the era of potent antibiotics often ends up with lethal outcome. It usually occurs in immunocompromised patients and requires intensive multidisciplinary treatment approach. We report a case of nontraumatic retropharyngeal abscess complicated by descending necrotizing mediastinitis in a 70-year-old man with insulin dependent diabetes mellitus. The patient was admitted to our hospital after clinical and radiological diagnosis of retropharyngeal abscess. During treatment for retropharyngeal abscess with antibiotic therapy and transoral incision, the patient showed mild clinical improvement but his condition suddenly aggravated on day 4 of hospital stay. He had high fever, chest pain with tachypnea, tachycardia, hypotension, and showed signs of occasional disorientation. Emergency computed tomography (CT) scan of the neck and thorax showed inflammation in the retropharyngeal space, as well as thickening of the upper posterior mediastinum fascia with the presence of air. Emergency surgery including cervicotomy and drainage of the retropharyngeal space and posterior mediastinum was performed. The patient promptly recovered with improvement of the clinical status and laboratory findings. After 16 days of treatment he was discharged from the hospital in good condition. Descending necrotizing mediastinitis can be a serious and life threatening complication of deep neck infection if the diagnosis is not quickly established. Besides inevitable application of antimicrobial drugs, good drainage of the mediastinum is necessary. We believe that transcervical approach can achieve high-quality drainage of the upper mediastinum, especially if it is done timely as in this case. Its efficacy can be verified by intensive monitoring of the patient clinical condition, by CT scan of the thorax, and by laboratory tests. In the case of inefficacy of this type of drainage, subsequently some other, more aggressive transthoracic methods of drainage can be done.

Aspergillus Mediastinitis after Orthotopic Heart Transplantation: A Case Report

A 55-year-old woman was admitted for orthotopic heart transplantation. Her medical history was notable for multiple cardiovascular problems, including ischemic cardiomyopathy that necessitated circulatory support with a left ventricular assist device. Five weeks after undergoing orthotopic heart transplantation, she developed Aspergillus calidoustus mediastinitis, for which she underwent a prolonged course of antifungal treatment that comprised (in sequence) posaconazole for 11 days, voriconazole for 10 days, and amphotericin B for 42 days. During this period, she also underwent repeated mediastinal drainage and sternal débridement, followed by sternal wiring and coverage with bilateral pectoralis advancement flaps. Four months postoperatively, she was discharged from the hospital with a successfully controlled infection and a healed sternum. To our knowledge, only 3 previous cases of Aspergillus mediastinitis after orthotopic heart transplantation have been reported in the literature, none of which was Aspergillus calidoustus.

[A case of parapharyngeal space infection followed abdominal pain]

Descending necrotizing mediastinitis that has an abdominal pain as a main clinical manifestation is seldom. Here one case is reported. At the beginning, the patient had pharyngalgia and his swallowing was not smooth. After that, abdominal pain became a main symptom. Pharyngalgia relieved . However CT showed mediastinal infection. Surgical drainage,antibiotics treatment and nutritional support were performed. The patient was cured.

[Successful treatment of Candida albicans mediastinitis after open-heart surgery using vacuum-assisted closure device]

An 82-year-old man suffered from Candida albicans mediastinitis following emergency aortic valve replacement. After repeated debridement of the anterior portion of the mediastinum, we applied a vacuum assisted closure device with UrgoTul Absorb placed on the right ventricle. Despite relatively short-term application of this device, mediastinitis was cured in combination with transposition of the great omentum.

Clinical study on cervical phlegmons

The purpose of this paper is to develop an algorithm for the diagnosis and treatment of cervical phlegmons in order to increase the diagnostic accuracy, to reduce the intra and postoperative risks and complication rates and to increase the number of cases with restitutio ad integrum. This is a retrospective clinical study on 21 patients diagnosed with cervical phlegmon. The study group consists of patients with lateral and retropharyngeal phlegmon (18 cases, of which two pharyngeal or cervical oesophagus effractions by foreign body- chicken or fish bone - with pneumomediastinum), retropharyngeal abscess and posttraumatic mediastinal (one case),peritonsillar phlegmon fused in the parapharyngeal space complicated by parapharyngeal haemorrhage after spontaneous drainage of purulent collections (2 cases). Surgical treatment was applied in all cases, associated with intravenous antibiotic medication; the treatment was individualized according to the particularities of each case: the location and extent of the phlegmon, complications, duration of evolution, mechanisms of production, etiology, associated general conditions, age and, not least, the patient's choice.

Descending necrotizing mediastinitis: a conservative approach

Descending necrotizing mediastinitis (DNM) is a now-rare complication of dental and pharyngeal infections. Reports in the literature have emphasized the need for early, aggressive surgical intervention. We present a case of DNM with bilateral empyemas that arose secondary to a perforated pharyngeal abscess. The patient was successfully managed conservatively with intravenous antibiotics and intercostal drainage. We conclude that conservative management with antibiotics and image-guided percutaneous pleural drainage may be initially appropriate for the stable patient.

[Epiglottitis and necrotizing mediastinitis in a middle-aged man]

Acute epiglottitis is nowadays a rare bacterial infection. Airway management and promptly started antimicrobial medication are essential in the treatment. Descending necrotizing mediastinitis is a life-threatening bacterial infection that typically spreads from an odontogenic, pharyngeal or neck infection. Despite the vagueness of symptoms, diagnosis must be made quickly. Owing to the high mortality rate, aggressive surgical treatment is indicated.

[Vacuum-assisted closure in a patient with methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after thoracic aortic surgery]

Mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) is a serious complication in cardio-thoracic surgery. In mediastinitis cases, acute thoracic aortic graft infection is a lethal status. We described a successful treatment of MRSA thoracic graft infection by V.A.C. ATS therapy. Ascending aortic graft replacement was performed in a 55-year-old man, and deep mediastinitis by MRSA occurred on postoperative day 6. On postoperative day 8, negative pressure wound therapy (NPWT) using a home-made system, was carried out after re-sternotomy, debridement of inflammatory tissues and irrigation. Following the 1st NPWT, V.A.C. ATS therapy was introduced. MRSA vanished from the mediastinum after V.A.C. ATS therapy, and the mediastinum was closed with the omentum. He was discharged 43 days after the 1st operation. We consider that the advantage of V.A.C. ATS therapy is "making a bed-side free status" in even mediastinitis patients, which enables active walking and reinforcement of physical strength. V.A.C. ATS therapy might be useful for the treatment of MRSA mediastinitis.

Acute mediastinitis due to extravasation of parenteral nutritional formula via a central venous catheter

Mediastinitis is a complication generally associated with thoracic surgery. Its occurrence after placement of a central venous catheter is uncommon, and only a few cases have been reported. An 83-year-old man who had mediastinitis due to extravasation of parenteral nutritional formula via a central venous catheter is presented. The signs and symptoms, diagnosis, and treatment of this unusual complication are described. This complication should be included in the differential diagnosis of mediastinitis in patients with a central venous catheter in place who have not had thoracic surgery.

[The immune reactions by the esophagus injuries, complicated by mediastinitis]

The comparative analysis of 56 immunograms of patients with mediastinitis, caused by the esophagus trauma is represented. The mean values of 9 immunologic parameteres (the so called "norm of the pathology") were set for patients with noncomplicated mediastinitis. A novel method of the immune status evaluation for the patients with the acute surgical conditions and SIRS has been suggested. If early applied, the method allows substantive immunotherapy for such patients.

[Diffuse cervical cellulitis and descending mediastinitis]

PURPOSE OF THE STUDY

The principal objective is to evaluate the circumstances of diagnosis and the treatment of cervical cellulitis and descending mediastinitis.

MATERIAL AND METHOD

It is about a retrospective study concerning ten patients, hospitalized between January 2000 and July 2011 in the University Hospital of Amiens for cervical cellulitis and descending mediastinitis, included according to Estrera's criterion.

RESULTS

The starting point was oropharyngeal (tonsillitis) in 70% of the cases. The three main germs were Streptococcus spp, Streptococcus milleri and Prevotella spp. The diffusion of the infection was done mainly by retropharyngeal way. 70% presented a mediastinitis associated to cellulitis. All the patients were operated by cervical approach, two profited from an associated thoracic way. Only four patients did not have any complication of their cellulitis. One patient died.

CONCLUSION

The early diagnosis of this pathology proves to be of primary importance. The treatment must be "aggressive". The drainage of mediastinitis proves to be sufficient by trans-cervical way in the event of the involvement of the higher part of the mediastinum (mediastinitis Endo type I) whereas a thoracotomy appears essential in the event of involvement beyond the carina (mediastinitis Endo type II).

[Acute mediastinitis]

The authors give an outline of the issue of acute mediastinitis. It is a severe infection of connective tissue of the mediastinum. Timing of recognition and accuracy of drainage are the most essential conditions of successful treatment. Acute mediastinitis may be divided in the postoperative sternal infections with infection of the mediastinum, mediastinitis due to perforation of the aero-digestive tract and descending necrotizing mediastinitis. The authors describe etiopathogenesis, diagnostics and therapy in each particular type of mediastinitis.

Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response

Fibrosing mediastinitis (FM) is a rare disorder characterized by the invasive proliferation of fibrous tissue within the mediastinum. FM frequently results in the compression of vital mediastinal structures and has been associated with substantial morbidity and mortality. Its pathogenesis remains unknown. However, in North America most cases are thought to represent an immune-mediated hypersensitivity response to Histoplasma capsulatum infection. To characterize the clinical disease spectrum, natural disease progression, responses to therapy, and overall survival, we retrospectively analyzed all 80 consecutive patients with a diagnosis of FM evaluated at Mayo Clinic, Rochester, MN, from 1998 to 2007. Furthermore, we characterized the adaptive immune response in 15 representative patients by immunohistochemistry. The majority of patients presented with nonspecific respiratory symptoms due to the compression of mediastinal broncho-vascular structures. Chest radiographic imaging most frequently revealed localized, invasive, and frequently calcified right-sided mediastinal masses. Most patients had radiographic or serologic evidence of previous histoplasmosis. In contrast to earlier reports summarizing previously reported FM cases, the clinical course of our patients appeared to be more benign and less progressive. The overall survival was similar to that of age-matched controls. There were only 5 deaths, 2 of which were attributed to FM. These differences may reflect publication bias associated with the preferential reporting of more severely affected FM patients in the medical literature, as well as the more inclusive case definition used in our consecutive case series. Surgical and nonsurgical interventions effectively relieved symptoms caused by the compression of mediastinal vascular structures in these carefully selected patients. In contrast, antifungal and antiinflammatory agents appeared ineffective. Histologic examination and immunostaining revealed mixed inflammatory infiltrates consistent with a fibroinflammatory tissue response in these histoplasmosis-associated FM cases. The immune cell infiltrates included large numbers of CD20-positive B lymphocytes. As B lymphocytes may contribute to the pathogenesis of the disease, therapeutic B-cell depletion should be investigated as a therapeutic strategy for FM.

[Successful conservative therapy for mediastinitis caused by multiple esophageal perforations]

A 77-year-old man was admitted to our hospital on a diagnosis of acute mediastinits, 17 days after he had high fever. Computed tomography of the chest revealed an abscess cavity in the left upper mediastinum. Endoscopic examination showed multiple pin-hole perforations in the upper esophagus from 23 to 24cm distal from the incisors and drainage through the perforation. We diagnosed acute mediastinitis caused by multiple esophageal perforations of unknown etiology. We initiated conservative therapy. Oral intake was restarted on the 17th day because radiological examination showed the esophageal perforation had closed. The patient was discharged on the 36th day from admission. Although mediastinitis caused by esophageal perforation often demands surgical treatment, conservative nonoperative therapy was successful in this patient.

[Diagnostics and surgical treatment of the posttraumatic septic mediastinitis]

Treatment results of 38 cases of septic mediastinitis for the last 17 years were analyzed. The frequency of mediastinitis as a complication of the penetrating wound was 0.28%, and of the closed thoracic trauma - 0.1%. Reasons and risk factors of the mediastinitis development have been revealed. The enlargement of the mediastinum on the X-ray allowed the primary diagnostics of suspicion on the mediastinitis in 39.5% of cases. The spiral computed tomography provided information for the further treatment options. The mediastinum drainage was an effective method of treatment, providing the improvement in 69.6% patients after penetrating wound and in 73.3% after the closed thoracic trauma.

[The diagnostics and treatment of the postoperative mediastinitis]

Treatment results of 48 patients with mediastinitis after the open cardiac surgery were analyzed. The main mediastinitis risk factors were: the chronic obstructive lung desease, diabetes mekkitus, severe cardiac insufficiency, prolonged operation, the use of artificial blood circulation and sterna instsbility. Major infective agents of mediastinitis were the Gram-positive cocci. The treatment options varied from the prolonged antibiotic therapy to plastic reconstructive surgery, which were determined by the severity of mediastinitis.

Is post-sternotomy mediastinitis still devastating after the advent of negative-pressure wound therapy?

In this study, we reviewed a 15-year experience with the treatment of a severe sequela of cardiac surgery: post-sternotomy mediastinitis. We compared the outcomes of conventional treatment with those of negative-pressure wound therapy, focusing on mortality rate, sternal reinfection, and length of hospital stay.We reviewed data on 157 consecutive patients who were treated at our institution from 1995 through 2010 for post-sternotomy mediastinitis after cardiac surgery. Of these patients, 74 had undergone extensive wound débridement followed by negative-pressure wound therapy, and 83 had undergone conventional treatment, including primary wound reopening, débridement, closed-chest irrigation without rewiring, topical application of granulated sugar for recurrent cases, and final plastic reconstruction with pectoral muscle flap in most cases.The 2 study groups were homogeneous in terms of preoperative data and operative variables (the primary cardiac surgery was predominantly coronary artery bypass grafting). Negative-pressure wound therapy was associated with lower early mortality rates (1.4% vs 3.6%; P = 0.35) and significantly lower reinfection rates (1.4% vs 16.9%; P = 0.001). Significantly shorter hospital stays were also observed with negative pressure in comparison with conventional treatment (mean durations, 27.3 ± 9 vs 30.5 ± 3 d; P = 0.02), consequent to the accelerated process of wound healing with negative-pressure therapy.Lower mortality and reinfection rates and shorter hospital stays can result from using negative pressure rather than conventional treatment. Therefore, negative-pressure wound therapy is advisable as first-choice therapy for deep sternal wound infection after cardiac surgery.

Fibrosing mediastinitis causing acute ostial left main myocardial infarction

This report describes an unusual etiology of acute coronary syndrome. A 48-year-old female presented with anginal chest discomfort and was found to have evidence of acute pulmonary edema requiring mechanical ventilation. She underwent emergency coronary angiography and stenting of the culprit left-main artery ostial discrete stenosis. Subsequent echocardiography and magnetic resonance imaging revealed severe aortic regurgitation and periaortic valve tissue infiltrates. Pericardiectomy and mediastinal mass biopsy were performed which indicated the pathology of fibrosing mediastinitis.

Changes in cardiac pumping efficiency and intra-thoracic organ volume during negative pressure wound therapy of sternotomy wounds, assessment using magnetic resonance imaging

Knowledge on the effects of negative pressure wound therapy (NPWT) on the intra-thoracic organs is limited. The present study was performed to investigate the effects of NPWT on the volume of the intra-thoracic organs, using magnetic resonance imaging (MRI), in a porcine sternotomy wound model. Six pigs underwent median sternotomy followed by NPWT at -75, -125 and -175 mmHg. Six pigs were not sternotomised. MR images covering the thorax and heart were acquired. The volumes of the thoracic cavity, lungs, wound fluid and heart were then determined. The volumes of the thoracic cavity and intra-thoracic organs increased after sternotomy and decreased upon NPWT application. The total heart volume variation, which is inversely related to cardiac pumping efficiency, was higher after sternotomy and decreased during NPWT. NPWT did not result in the evacuation of wound fluid from the bottom of the wound. NPWT largely closes and restores the thoracic cavity. Cardiac pumping efficiency returns to pre-sternotomy levels during NPWT. This may contribute to the clinical benefits of NPWT over open-chest care, including the stabilizing effects and the reduced need for mechanical ventilation.

[Mediastinal abscess caused by self-mutilation of the hypopharynx]

A 44-year-old male with a non-specific psychological disturbance was diagnosed with septicemia. The patient had unsuccessfully tried to remove what he believed to be a fish bone from his throat. Computed tomography revealed a descending abscess in the mediastinum along with perforations in the pharynx and oesophagus to the mediastinum. He was treated with antibiotics and drainage of the abscess and discharged after six weeks without sequelae. Sharp foreign bodies in the pharynx should be removed professionally to avoid perforation and thus mediastinitis.

[Management of deep device related infection in patient implanted with mechanical cardiac support device using V.A.C. system]

Infection remains the most significant cause of morbidity and mortality in pacients implanted with mechanical circulatory support devices (MCSD), reaching prevalence of 40-60% according various authors. Successful treatment of the whole spectrum of infectious complications is the basic determinant in archieving good results in MCSD patients. The treatment involves standard surgical procedures, as well as the use of vacuum assisted closure (V.A.C.) therapy in the last few years. We demonstrate successful management of deep device related infection using V.A.C therapy in a patient with MCSD, giving him the opportunity to heart transplantation, and thereafter successful treatment of poststernotomy mediastinitis in this imunosupressed pacient after heart transplantation.

[The association of VAC® therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps in the management of postoperative mediastinitis in an obese and diabetic patient]

Postoperative mediastinitis is one of the most worrisome complications after heart surgery. Until now there is no universally accepted strategy in the management of this infectious complication. Recently, various novel techniques like negative pressure therapy and titanium plates sternal reconstruction have allowed a dramatic decrease of mortality and morbidity after mediastinitis. We report the case of a diabetic patient suffering from morbid obesity who developed a severe postoperative mediastinitis after a coronary artery bypass; she was successfully treated by combining negative pressure therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps.

[Descending necrotizing mediastinitis of odontogenic origin]

BACKGROUND

Descending necrotizing mediastinitis (DNM) following an oropharyngeal infection is a rare disease with a rapid course and a mortality rate of up to 40%. The aim of this study, is to outline the diagnosis and the appropriate treatment of DNM.

METHODS

A retrospective study (1986-2007) of patients with DNM was made. Only patients with cervical cellulitis associated with DNM were included.

RESULTS

Eight men and two women with an average age of 43 years were treated. Five had diabetes. The average for diagnosis and treatment was eight days. In eight cases, we found a dental origin and in two cases a pharyngeal origin. The diagnosis of DNM was made thanks to cervico thoracic CT scan in six cases. In the others patients, they had at presentation clinical and radiological evidence of mediastinal diffusion. All patients were treated by broad spectrum antibiotherapy. All had cervical drainage. Mediastinal drainage was made by cervical approach in 2 two cases and via a right thoracotomy in eight cases. Eight patients died.

CONCLUSION

Odontogenic DNM is a rare disease with rapid course. Clinical diagnosis is difficult and early recognition with a low thresold for CT scanning is essential. CT is also useful for the treatment and in the post operative assessment. All affected tissue plane must be debrided. Surgical management and mediastinal drainage remain controversial about the indication of thoracotomy.

[Clinical and therapeutical considerations regarding odontogenic acute mediastinitis]

Odontogenic acute mediastinitis is an polymicrobial infections caused in most cases by gram negative and anaerobic germs. The odontogenic origin of the cases in this study was based on anamnestic inquiry of the patients, which reveales a dental treatment 7-15 days before the diagnosis of acute mediastinitis was established. Clinical features are often nonspecific at the debut of this affection; septic shock could appear suddenly associated with multiple systems and organs failure. This is the explication why, some of these patients presented septic shock when are diagnosed. In this situations, when acute mediastinitis is suspected, based on clinical and imaging findings, it must be confirmed by surgical exploration and perioperative bacteriological evaluations. Positive diagnosis is based on clinical features associated with labs and imaging studies. Surgery plays an important role in therapy of acute mediastinitis: debridement and drainage of mediastinum with subsequently lavage of it, using antiseptic solutions. Broad spectrum antibiotherapy should be administrated immediately, before antibiogram is ready.