Acute Mediastinitis Research Articles

Non-Surgical Management of Methicillin-Sensitive Staphylococcus Aureus Bacteremia-Related Mediastinitis.

Acute mediastinitis is rarely caused by haematogenous spread of a remote infection. In this respect, since the only medical therapy is usually unsuccessful, treating acute mediastinitis with no source of infection detected is very challenging and management not standardized. In this case report, we describe non-surgical management experience of acute mediastinitis caused by methicillin-sensitive Staphylococcus aureus. In a 79-year-old man judged not eligible for cardiac surgery, we attempted the infection source control through vacuum-assisted closure therapy, together with antimicrobial therapy. We observed gradual clinical, laboratory and radiologic improvements: reduced swelling and normalization of the white blood cell count and C-reactive protein level were associated with reduction in size of a periaortic abscess. We managed a clinical condition with high mortality risk with chronic antimicrobial therapy alone, a strategy that is rarely considered. With this medical strategy we achieved an optimal response to a clinical picture that does not allow any other approach. Mediastinitis is a rare but severe infection with a high mortality rate.Chronic antimicrobial therapy can be an effective strategy in high surgical risk patients.The present case demonstrates good tolerability of lifelong antibiotic therapy.

Comparative analysis of CO2 laser and ultracision harmonic scalpel for endoscopic treatment of Zenker's diverticulum using a propensity score: A retrospective observational study

ObjectivesZenker's diverticulum (ZD) is a progressive condition that can cause dysphagia and aspiration. Endoscopic cricopharyngeal myotomy (ECPM) is the gold standard treatment for ZD, but there are various techniques available. We aimed to compare the efficacy and safety of the ultrasonic harmonic scalpel (UHS) versus the CO2 laser (CO2L) for ECPM in ZD. DesignWe led an observational study. The main composite outcome consisted in persistence of postoperative dysphagia OR recurrence/reoperation of symptomatic ZD within two years postoperatively. Surgery was considered effective when no dysphagia within two years postoperatively. The secondary outcome was the occurrence of acute mediastinitis within 72 h postoperatively. A propensity score was built to adjust for differences observed between non-randomized groups. Additional sensitivity analyses were performed. SettingAll patients with ECPM surgery for ZD were included from 2011 to 2018 in a single tertiary center. Patients with failure of endoscopic exposition were excluded. ParticipantsThe study included 86 patients who underwent ECPM with either the CO2L (n = 53) or UHS (n = 33) technique. ZD size and other demographic variables were comparable between the groups. Main outcome measuresUHS had superior efficacy compared to CO2L (relative risk of failure = 0.29; 95 % confidence interval: 0.05–1.0; p = 0.05), but there was a higher incidence of mediastinitis in the UHS group (12 % vs. 4 %), although this was not statistically significant. Results and conclusionThe UHS technique appears to be an effective technique for ECPM in ZD patients but its safety remains to explore by further larger studies.

MEDIASTINITIS, WHAT SHOULD WE KNOW: A CASE REPORT OF PNEUMOPYOTHORAX WITH SUSPECTED MEDIASTINITIS IN A 67-YEAR-OLD MALE

Mediastinal disease consists of various diagnoses that have different characteristics, and the severity is not the same. The mediastinal disease diagnosis is often delayed because of the non-specific and sometimes vague presentation and clinical symptoms. One of the commonly missed diagnoses is acute mediastinitis, which is usually presented with fever, pleuritic or retrosternal chest pain, and an inflammatory syndrome. Careful clinical evaluation and radiological correlation are essential when diagnosing mediastinitis, as well as the need to differentiate it from mediastinal infiltration due to malignancy. In this case report, we describe a 67-year-old male, who was referred with pyothorax, cough, and 10 kg of weight loss in the last 1 month. The patient then underwent a CT examination with contrast to establish the diagnosis. Finally, the patient was diagnosed with pneumopyothorax with suspicion of mediastinitis and abscess formation. The lessons learned from this case include the need for recognizing features of mediastinitis, such as fat stranding and fluid collection, which may contain gas locules, in the mediastinal region. The aim of this case report is to increase awareness of early signs of mediastinitis so that prompt management can be initiated as early as possible. Keywords: Mediastinitis, pneumopyothorax, CT thorax

Descending Necrotizing Mediastinitis in Healthy Young Adults: The Fatal Consequence of the Delayed Help

Introduction: Descending necrotizing mediastinitis is one of the most lethal forms of acute mediastinitis. It originates from an odontogenic or deep neck infection, which descends to the mediastinum through the fascial planes. It is a rare condition, but mortality rates remain high, especially in the presence of comorbidities or predisposing factors. Delay in diagnosis has been shown to be one of the most important factors for the disease outcome. Therefore, early diagnosis and treatment by a multidisciplinary team are of utmost importance. Case series: Four healthy young males with descending necrotizing mediastinitis were treated at our institution. None of them had any comorbidities, but all of them waited between 3 and 4 days before seeking medical help. Upon their arrival at the hospital, in addition to the presence of a severe neck infection, the presence of mediastinitis was also found. Despite the timely surgical treatment of both the source of the infection and the mediastinitis, three of the four cases had a fatal outcome. Conclusion: We believe that the time factor is of greater importance for the outcome of acute descending mediastinitis than the factors of age and presence of accompanying diseases. Proper and rapid treatment by a multidisciplinary team is essential, even for young and healthy people.

Ludwig's angina asociate with acute mediastinitis as a consequence of a non odontogenic infection. Case report. Instituto de prevision social

El 70-90% de los casos de angina de Ludwig se deben a procesos infecciosos de origen dental. Un menor porcentaje se deben a casos como: sialoadenitis, abscesos amigdalinos o trauma maxilofacial. Existen pocos reportes de casos de orígenes no odontogénicos, constituyendo este origen como raro. El tratamiento es similar en ambos casos, teniendo como claves: el diagnóstico temprano, antibioticoterapia dirigida y drenaje quirúrgico oportuno.

Ectopic pancreas tissue in the posterior mediastinum

The occurrence of ectopic pancreas in the mediastinum is rare. Herein, we report a 22-year-old female who presented with right shoulder pain, dysphagia, fever and headaches. Chest computer tomography revealed a mass in the posterior mediastinum with accompanying signs of acute mediastinitis. Needle biopsy and fine-needle aspiration revealed ectopic gastral tissue and ectopic pancreas tissue, respectively. Surgical resection was attempted due to recurring acute pancreatitis episodes. However, due to chronic-inflammatory adhesions of the mass to the tracheal wall, en-bloc resection was not possible without major tracheal resection. Since then, recurring pancreatitis episodes have been treated conservatively with antibiotics. We report this case due to its differing clinical and radiological findings in comparison to previous case reports, none of which pertained a case of ectopic pancreas tissue in the posterior mediastinum with recurring acute pancreatitis and mediastinitis.

The unlikely suspect: A case of isolated pulmonary mucormycosis-induced acute mediastinitis in an immunocompetent patient.

The unlikely suspect: A case of isolated pulmonary mucormycosis-induced acute mediastinitis in an immunocompetent patient.

Особенности хирургического лечения первичных острых гнойных медиастинитов

Особенности хирургического лечения первичных острых гнойных медиастинитов

Demographic, clinical, and paraclinical features of patients operated with the diagnosis of acute descending necrotizing mediastinitis: a retrospective study in Southern Iran

IntroductionDescending necrotizing mediastinitis (DNM) is a type of acute mediastinitis that is rarely reported but is regarded as a fatal disease despite improvements in technological methods and antibiotic therapies. We aimed to determine the demographic, clinical, and paraclinical features of patients diagnosed with acute DNM.MethodsIn this retrospective study, patients’ hospital records with a diagnosis of DNM admitted to the Namazi hospital in southern Iran during 18 years (2002–2019) were reviewed. Demographic and clinical features were recorded and subsequently analyzed via SPSS 22.ResultsOut of 67 mediastinitis patients, 25 (37.3%) were diagnosed as DNM with an average age of 37.2 ± 16.7 years, and 68% were male. Regarding etiology, 52.0% were due to neck infection. Based on the technique of surgery, 52% of the patients underwent the combined method, which was mostly among type I and IIA DNM, while thoracotomy was mostly performed on type IIB DNM (P = 0.08). Based on the incision, type IIA and IIB had the highest frequency of thoracotomy and cervicothoracic incisions (P = 0.02 and 0.002). Puss discharge was significantly lower in type I DNM (P = 0.01). Based on the presenting symptoms of our patients, the majority (72.0%) had a chief complaint of neck pain, followed by chills and fever (48%). There were no reports of mortality during our short-term follow-up.ConclusionWe report one of the largest retrospective studies of DNM patients in our referral center, with a high prevalence of the disease among younger populations, especially under 40 years. The method of treatment should be chosen based on the extent of infection and can be limited to neck exploration in upper mediastinal infections, though thoracic or combined approach in more broad infections.

Poorly controlled diabetes mellitus is strongly associated with descending necrotizing mediastinitis of odontogenic origin

We hypothesized that poorly controlled diabetic status may be a negative prognostic factor for acute mediastinitis of odontogenic origin, and we conducted a cohort study to verify this hypothesis. Data were collected on all consecutive patients diagnosed with maxillofacial infections of odontogenic origin who received surgical treatment in the Oral and Maxillofacial Surgery Department. All patients included in the study were divided into 4 groups based on the presence or absence of diabetes and mediastinitis. Poorly controlled diabetic status constituted our primary predictor variable, and the occurrence of descending necrotizing mediastinitis was the outcome variable. All 7 patients with poorly controlled diabetes mellitus were complicated with descending necrotizing mediastinitis. An exact Fischer test was conducted to investigate the association of poorly controlled diabetes mellitus with descending necrotizing mediastinitis in patients admitted for surgical treatment of their maxillofacial collection. The result was significant at P < .01. This study represents the first scientific attempt to associate poorly controlled diabetes mellitus with descending necrotizing mediastinitis of odontogenic origin. Our results show evidently that these patients are more susceptible to deep space infections, which subsequently spread faster and are much more difficult to control.

A current approach to acute mediastinitis

Acute mediastinitis is still among the major causes of high mortality despite advances in antibiotic therapies, intensive care support, and novel diagnostic techniques. Mediastinitis may develop due to esophageal perforation, by a downward spread of neck infection, or after cardiothoracic surgery. While computed tomography is the most preferred imaging technique in diagnosis, broad-spectrum antibiotic therapy and surgical debridement are the mainstay of the treatment. It is essential to combine multiple interventions, such as appropriate antimicrobial prophylaxis, minimization of contamination, elimination of preoperative nasal S. aureus carriage, and the adoption of relevant surgical techniques, to prevent particularly postoperative mediastinitis.

SEVERE DIABETIC KETOACIDOSIS WITH AN ACUTE MEDIASTINITIS COMPLICATING A FUNGALBRONCHOPNEUMONIA: A PEDIATRIC CASE

Introduction:Type 1 diabetes mellitus (T1DM) is the most common metabolic disorder occurring in childhood with significant morbimortality. Uncontrolled diabetic patients are exposed to fatal hyperglycemic emergencies such as Diabetic ketoacidosis (DKA) characterized by hyperglycemia, acidosis, and ketosis. Although infections remain the predominant precipitating factors for (DKA), its association with mediastinitis is, to date, a rare situation. The objective of this study was to bring the importance of diagnosing the underlying etiological precipitants during DKA to enhance the management of this complication and reduce its mortality. Case Description:The authors report during this article the case of a 7-year-old male patient, known type 1 diabetic on insulin therapy for 3 years, admitted to the pediatric intensive care unit in AbderrahimHarrouchi hospital in Casablanca for severe diabetic ketoacidosis with febrile reparatory distress and whom the non-improvement of the symptomatology leads us to diagnose an acute mediastinitis complicating its fungal bronchopneumonia. Discussion:This report will review the precipitant factors, relayed by literature, associated with acute metabolic decompensation of diabetes in pediatric patients and the incidence of fungal lung infection in the diabetic population.The authors also highlight the lack of scientific data concerning the mediastinitis complicating pulmonary infections, especially in the pediatric population. Conclusion:Acute mediastinitis is a serious medical condition, commonly misdiagnosed due to the polymorphic and unspecific clinical presentation that can be related to the bronchopneumonia itself. This fatal complication being an etiological factor of a DKA considerably increases its mortality.

Acute Mediastinitis Caused by Parapharyngeal Abscess and Carotid Sheath Infection: Case Report

Acute Mediastinitis Caused by Parapharyngeal Abscess and Carotid Sheath Infection: Case Report

ODONTOGENIC PHLEGMON OF THE MAXILLOFACIAL AREA, COMPLICATIONS AND PROGNOSIS

The purpose of the study was analyzed the case of a patient M. admitted to the department of thoracic surgery in connection with a diagnosis confi rmed by MRI: gangrenous mediastinitis, in which the pathway of the purulent contents from the mandibular apparatus was completely and accurately described (1 molar left) with a lesion of the periosteum, further into the posterior- pharyngeal space and through the anatomical intercellular spaces of the neck to the mediastinum for 4 days. According to CT scanner of organs of the chest cavity we can see that CT scan is a sign of acute gangrenous mediastinitis with a primary process in the submandibular region. In the left parts of the lower jaw there is a small defect in the outer compact plate for up to 4.0 mm. In the soft tissues of the neck, along the whole length from the level of the larynx, multiple gas accumulations are determined both in the prevertebral space and on both sides, symmetrically under the nival muscles, where there is especially a lot of gas, and along the vascular bundles. There is a gas in the region of the fl oor of the mouth, the chin-tongue muscle. All tissues are swollen because of what anatomical structures do not diff erentiate. The process goes through the interfascial spaces, as well as along the pharynx, larynx, thyroid gland in the mediastinum, where gas is determined along all main arteries and trachea. Then it spreads along the anterior and posterior mediastinum to the diaphragm along the heart and esophagus. In its course, there is infi ltration of the tissue of the posterior mediastinum, and in the anterior one there is more pronounced accumulation of fl uid, more to the right, especially near the right atrium, where its thickness reaches 25.0 mm and there is a reaction of the adjacent parts of the right lung. Osteo-destructive changes are not detected. Thus we observed the pathway of the spread of the purulent infl ammatory process from teeth of the lower jaw to the mediastinum cavity as a consequence of infraction of asepsis (ules therefore a patient M. who had been operated twice and had clinical death was discharged from the department of the hospital with positive dynamics.

A CASE OF SUCCESSFUL COMBINED SURGICAL TREATMENT OF A WOUNDED WITH PURULOUS MEDIASTINITIS AFTER CHEST AND NECK INJURY OF FIRE ORIGIN

Resume. The purpose of the study was to reveal the main features of the development of purulent mediastinitis in a wounded person with penetrating gunshot wounds of the chest and neck in order to further improve the diagnosis and treatment of this difficult complication. The work reports on the injured K., 29 years old, with acute purulent-necrotic mediastinitis and late bilateral empyema of the pleura caused by a gunshot wound to the chest and neck. With early diagnosis of suppurative mediastinitis due to penetrating gunshot wounds of the chest and neck, active surgical tactics including wound dressing, drainage, massive antibiotic therapy, and adequate postoperative care with intensive care generally help to save the patient's life.

Acute mediastinitis, mediastinal granuloma, and chronic fibrosing mediastinitis: A review.

Acute mediastinitis is a rare infection that carries high morbidity and mortality. They are complications seen most often with deep sternal wound infections from surgeries with median sternotomies, oropharyngeal and odontogenic infections and esophageal perforations. These conditions should be promptly recognized and treated. Mediastinal granulomas are focal, mass-like lesions commonly resulting from prior granulomatous infections. They are regarded as benign, self-resolving lesions however can cause complications by compression of adjacent mediastinal structures. Chronic fibrosing mediastinitis is a rare, diffuse fibroinflammatory process most often seen with granulomatous infections and carries a worse prognosis than mediastinal granulomas especially when adjacent mediastinal structures are compromised. In this review, we discuss the epidemiology, etiology, clinical presentation, treatment and prognosis of acute mediastinitis, mediastinal granulomas, and chronic fibrosing mediastinitis.

Translated article] Acute Mediastinitis due to Spontaneous Rupture of a Thyroid Cyst

Translated article] Acute Mediastinitis due to Spontaneous Rupture of a Thyroid Cyst

Critical Preoperative Hemoglobin Value to Predict Anemia-Related Complications After Cardiac Surgery

Preoperative anemia is frequent in patients undergoing cardiac surgery and is associated with increased postoperative complications. The purpose of this observational study was to estimate the critical preoperative hemoglobin threshold associated with the occurrence of complications after cardiac surgery. A retrospective observational cohort study. A tertiary-care medical center from January 2019 to April 2020. A total of 1,004 patients undergoing elective cardiac surgery were included. None (observational study). The primary study endpoint was to define the hemoglobin threshold that predicted the occurrence of postoperative major complications after elective cardiac surgery. Postoperative complications were a composite criterion, including transient ischemic attack or stroke, myocardial infarction, acute kidney injury, respiratory failure, mediastinitis, or mesenteric ischemia. A discrimination threshold was determined by using receiver operating characteristic curves. The discrimination threshold for hemoglobin concentration with the best sensitivity/specificity ratio for the occurrence of postoperative complications was 13 g/dL for male patients and 11.8 g/dL for female patients. The incidence of postoperative complications was 17.2% in the total population. Independent risks were preoperative hemoglobin concentration, red blood cell transfusion, European System for Cardiac Operative Risk Evaluation II, and the type of surgery. The critical preoperative hemoglobin thresholds associated with the occurrence of postoperative complications with the best sensitivity/specificity ratio were 13 g/dL for men and 11.8 g/dL for women, which were very similar to the World Health Organization criteria defining anemia.

Acute Mediastinitis - Outcomes and Prognostic Factors of Surgical Therapy (A Single-Center Experience).

Purpose: The aims of this work were the retrospective analysis of a cohort of patients with acute mediastinitis treated at the authors’ worksite over a 15-year period and the identification of factors that significantly affect the outcomes of the therapy.Methods: During the period 2006–2020, 80 patients with acute mediastinitis were treated. Within the cohort, the following were observed: the causes and the type of acute mediastinitis, length of anamnesis, comorbidities, diagnostic methods, time from the diagnosis to surgery, types and number of surgical procedures, results of microbiological tests, complications, and outcomes of the treatment.Results: The most common type of acute mediastinitis was descending mediastinitis (48.75%). A total of 116 surgical procedures were performed. Ten patients in the cohort died (12.5%). Patients older than 60 years were at a 6.8 times higher risk of death. Patients with more than two comorbidities were at a 14.3 times higher risk of death. The presence of yeasts in the culture material increased the risk of death by 4.4 times.Conclusion: Early diagnosis, removal of the cause of mediastinitis, sufficient mediastinal debridement, and multiple drainage thereof with the possibility of continual postoperative lavage are essential for the successful treatment of acute mediastinitis.

A Case of Acute Mediastinitis due to Perforation of an Esophageal Epiphrenic Diverticulum during Follow-up of the Diverticulum

横隔膜上食道憩室は稀な疾患であり，食道運動障害や逆流症状を伴う場合は手術適応となる，今回，われわれは食道憩室穿孔・急性縦隔炎を発症し，ドレナージ術後に二期的な切除再建手術で良好な経過を得た症例を経験した．症例は68歳，男性．つかえ感を主訴に受診し，横隔膜上食道憩室を認め手術を予定していたが，自覚症状が消失したため本人の希望で経過観察としていた．経過中に食道憩室穿孔，急性縦隔炎を発症したため，緊急で腹腔鏡下経裂孔的縦隔ドレナージ術を施行した．縦隔炎改善後に胸腔鏡下食道亜全摘術を施行し，術後縫合不全をきたしたものの保存的に軽快し，術後35日目に退院とした．横隔膜上食道憩室は逆流などの症状を認めるが，憩室の拡大に伴い症状が自然軽快することがあり，穿孔の高リスクとなる可能性がある．憩室穿孔による急性縦隔炎を伴う食道憩室穿孔例には二期的手術が有効であった．