Mediastinal Collections Research Articles

Barotrauma-associated posterior tension pneumomediastinum, a rare cause of cardiac tamponade in a ventilated neonate: a case report and review of the literature

Ventilation-associated neonatal barotrauma comprises a spectrum of conditions including pneumothorax, pulmonary interstitial emphysema, pneumopericardium and pneumomediastinum. Whilst pneumothorax is common, mediastinal and particularly posterior mediastinal air collections are rare. We report the case of a neonate, presenting with life threatening pericardial tamponade secondary to posterior tension pneumomediastinum. The infant was successfully resuscitated with an emergency left lateral thoracotomy and chest drain insertion. We believe this to be the first such case reported in the literature. We discuss aspects of pathophysiology, diagnosis and management relating to posterior pneumomediastinum. Posterior pneumomediastinum is rare, but can potentially cause fatal tamponade. Such cases must be managed in a tertiary centre where cardiology and surgical expertize are available.

Successfully treated descending necrotizing mediastinitis through thoracotomy using a pedicled muscular serratus anterior flap

Descending necrotizing mediastinitis (DNM) is rare and aggressive. A 68-year-old female with no medical history, was admitted to our institution for cervical cellulitis. After a conventional medical treatment, multiple abscesses of the upper mediastinum appeared on computed tomography (CT) findings. Although two cervicotomies were performed, a new necrotic abscess appeared in the anterior upper and middle mediastinum. An extensive debridement of cellulitis and abscess extended to the pericardium was made by thoracotomy. Middle mediastinum and pericardium were covered and reconstructed by a right pedicled serratus anterior flap. After radical surgery, follow-up was uneventful. Early extensive and complete debridement of cervical and mediastinal collections and irrigation with broad-spectrum intravenous antibiotics is essential. Combined surgery is the best approach in DNM. The use of a pedicled muscular flap helps control the sepsis. In such cases, serratus anterior flap is a flap of choice because it is reliable and always available even in a skinny patient, contrary to omentum. In this life-threatening disease, an early aggressive combined surgery with debridement of all necrotic tissues extended to the pericardium if necessary associated with a pedicled flap is mandatory.

Diagnostic value of CT scan for closed chest injury

CT findings and complete clinical data of 185 cases with closed chest injuries were retrospectively analyzed.The diagnosis of 185 cases were pulmonary contusion ( n = 185 ),pulmonary laceration ( n = 35 ),Macklin effect ( n = 5 ) and lung herniation ( n = 1 ).CT findings of lung contusion appeared as thick and vagur lung marking (n =9),small points shadows (n = 12 ),blotchy shadows (n =48),small pieces shadows (n=10),ground-glass shadows (n=16),large pieces shadows (n =5),diffuse patchy clouding shadows (n = 17) or mixed lesions (n = 68).CT appearance of lung laceration included pulmonary hematomas (n = 12),cavitary lesions with air ( n = 19),cavitary lesions with air-fluid levels ( n = 53 ).Macklin effect appeared as bronchus-,pulmonary vessel-adjacent air collection and mediastinal air collection (n=5).Traumatic pulmonary hernia appeared as lung herniation through an intercostal space.Initial CT scan missed one case of pulmonary contusion and 2 cases of pulmonary laceration. Key words: Thoracic injury,closed; Tomography, X-ray computed

EUS-guided drainage of a mediastinal collection complicating FNA of a bronchogenic cyst

EUS has evolved significantly over the last decade, particularly with regard to its therapeutic capabilities. EUS-guided drainage of peripancreatic collections has become the accepted standard of care, with advantages over conventional techniques for non-bulging collections. 1 Furthermore, this technique has been extrapolated successfully for management of a variety of extraluminal collections, with high success rates and few complications. 2-7 We report the first case of EUS-guided drainage of a mediastinal collection that complicated EUS-guided FNA (EUS-FNA) of a bronchogenic cyst.

Generalized cystic lymphangiomatosis

A 2-year-old girl presented with acute shortness of breath and multiple subcutaneous nodules. Chest radiograph showed widening of the mediastinum. Contrast-enhanced CT of the thorax revealed interstitial thickening, lung nodules, pleural effusions (Fig. 1a, black arrow) and cystic mediastinal collections (Fig. 1a, white arrow). Sections of the abdomen showed ascites, multiple lowdensity lesions in the spleen (Fig. 1b, black arrow) and retroperitoneum (Fig. 1b, white arrow). No appreciable enhancement was noted following administration of contrast medium. Multiple osteolytic lesions with sclerotic margins were also detected in the vertebral bodies (Fig. 1b, black arrowhead). Drainage of the pleural effusions revealed chylothorax. Generalized lymphangiomatosis is a rare disease, characterized by a diffuse proliferation of lymphatic vessels that can involve any organ except the central nervous system [1]. Prognosis depends on the site and extent of the lymphangioma [1]. Imaging features are characteristic and crucial in the evaluation of the complete extent of disease and, thus, may contribute to clinical management of the disease by preventing initial misdiagnosis [2].

Citrobacter freundiicausing pharyngitis and secondary retropharyngeal abscess with intrathoracic extension to the diaphragm: minimally invasive management of a rare case

Citrobacter freundii is a rare but potentially aggressive cause of pharyngitis which may progress to retropharyngeal abscess with diaphragmatic extension. To raise awareness of: (1) citrobacter as a potential cause of head and neck infection, including retropharyngeal abscess; (2) a novel surgical approach to draining such an abscess; and (3) citrobacter's particular biological properties which may affect the clinical course. Case report. The abscess was drained via a minimally invasive posterior pharyngeal wall incision and placement of a suction catheter into the mediastinum through this incision. Residual intrathoracic collections were drained by the cardiothoracic team via percutaneous aspiration. The patient made a full recovery. Early recognition of citrobacter head and neck infections, an awareness of the peculiarities of the clinical course of such infections, and timely surgical intervention can prevent catastrophic outcomes. A minimally invasive approach to mediastinal collections can be considered as a viable alternative to open thoracotomy, which carries a high morbidity rate.

Boerhaave′s syndrome: Thoracolaparoscopic approach

We present a case of Boerhaave’s syndrome managed thoracolaparoscopically. A 45-year- old man presented with hydropneumothorax following severe retching. He was treated with Intercostal drainage insertion as the primary management and referred to a tertiary care centre. There endoscopic stapling was attempted, following which he developed a leak. He presented to us with severe sepsis and mediastinal collection on the ninth day following the perforation. We treated him with thoracoscopic mediastinal toilet, laparoscopic-assisted feeding jejunostomy and cervical oesophagostomy. The patient was managed conservatively. A computed tomography (CT) scan was repeated at intervals of 15 days. He was continued on full jejunostomy feeds. Regular assessment of the oesophagus injury was conducted via the CT scan. The patient had complete healing of the perforation at end of two months. His oesophagostomy was closed and he remained symptom-free at follow-up. We conclude that thoracoscopy has an important role to play in the management of patients with mediastinal sepsis and late presentation of Boerhaave’s perforation.

Diagnosis of Prosthetic Aortic Valve Endocarditis With Gallium-67 Citrate Single-Photon Emission Computed Tomography/Computed Tomography Hybrid Imaging Using Software Registration

Prosthetic valve endocarditis can be challenging to diagnose and is associated with high mortality rates even if recognized and managed early. We present a case of staphylococcal sepsis soon after aortic valve surgery and permanent pacemaker implantation for which conventional investigation with echocardiography and computed tomography (CT) failed to identify an infective focus. Subsequent gallium–single-photon emission CT (67Ga-SPECT) imaging with software registration of the SPECT data helped to correctly identify the prosthetic aortic value as the source of sepsis, with resolution of changes on subsequent imaging. A 70-year-old woman underwent bioprosthetic aortic valve replacement and coronary artery bypass grafting for symptomatic severe aortic stenosis and significant 2-vessel coronary disease. Her postoperative course was complicated by significant bradycardia necessitating dual-chamber permanent pacemaker implantation. She presented 3 months after surgery in a confused state, with low-grade pyrexia. The examination identified a soft systolic aortic murmur but no diastolic component, normal breath sounds, absence of cutaneous markers of endocarditis, and no evidence of …

Intrathoracic drainage of a perforated prepyloric gastric ulcer with a type II paraoesophageal hernia

BackgroundWith an incidence of less than 5%, type II paraesophageal hernias are one of the less common types of hiatal hernias. We report a case of a perforated prepyloric gastric ulcer which, due to a type II hiatus hernia, drained into the mediastinum.Case presentationA 61-year old Caucasian man presented with acute abdominal pain. On a conventional x-ray of the chest a large mediastinal air-fluid collection and free intra-abdominal air was seen. Additional computed tomography revealed a large intra-thoracic air-fluid collection with a type II paraesophageal hernia. An emergency upper midline laparotomy was performed and a perforated pre-pyloric gastric ulcer was treated with an omental patch repair. The patient fully recovered after 10 days and continues to do well.ConclusionType II paraesophageal hernia is an uncommon diagnosis. The main risk is gastric volvulus and possible gastric torsion. Intrathoracic perforation of gastric ulcers due to a type II hiatus hernia is extremely rare and can be a diagnostic and treatment challenge.

Retrospective study of descending cervical mediastinitis

Descending cervical mediastinitis can occur as a complication of oropharyhgeal and cervical space that spread to the mediastinum vis cervical space. Descending mediastinitis represent a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce high morality associated with the disease. Surgical management and a particularly optimal form of mediastinal drainage remain controversial. From 1998-2004, eighteen patients were treated in our institution. Surgical treatment consisted more than 2 times. Cervical drainage associated with drainage of the mediastinum through a thoracic approach in 11 patients with pleural drainage in 8 patients. The outcome was favorable in eleven patients who had mediastinum drained through thoracotomy. One patient who was not drained died with tracheo-oesophageal fistula. Main culprit neck space is pre and para tracheal space which lead to anterior, superior and posterior mediastinal collection in our series. The tracheostomy is of immense help not only in opening cervical space collections and also to secure a partially compromised airway.

Oesophageal perforation as a complication of primary pulmonary tuberculous lymphadenopathy in children

Involvement of the oesophagus by tuberculosis is rare, and erosion and perforation of the oesophagus by tuberculous lymphadenopathy is an unusual complication of primary pulmonary tuberculosis. There are very few reports describing both CT and contrast swallow appearances of these lesions. To describe the CT and contrast swallow appearances of oesophageal erosion and perforation by lymphadenopathy as a complication of primary pulmonary tuberculosis in children. Imaging of three children with confirmed pulmonary tuberculosis and oesophageal perforation was retrospectively reviewed. Tuberculosis was confirmed by culture in all three patients. Contrast swallow demonstrated a contained leak in two patients and a tracheo-oesophageal fistula in one. Two patients had mediastinal air and one patient had a mediastinal collection on CT. All patients had features diagnostic of pulmonary tuberculosis on CT. The imaging features comprise leakage of contrast medium with or without fistula formation on contrast swallow, large low-density lymph nodes on CT, and mediastinal air. The use of retrievable stents is a promising idea in this condition.

Transabdominal Approach for Management of Boerhaave's Syndrome

Several transthoracic approaches have been described for the surgical management of Boerhaave's syndrome that carry their own morbidity in patients who can be systemically unwell at presentation, and best practice is not established. We introduce a novel transabdominal approach to manage the perforation and spare these patients the trauma of a thoracotomy. Four patients with spontaneous esophageal rupture were managed using a transabdominal approach. Postoperative complications, length of intensive care unit stay, postoperative hospital stay, time to oral intake, and morbidity and mortality were used as outcome measures. After operation, the median intensive care unit stay was 4 days (range, 0-5) in patients who required a median of 10.5 days (range, 6-17) to establish oral intake. One patient required a transthoracic drainage of an empyema and one patient required percutaneous drainage of a mediastinal collection. The median length of stay was 38 days and there was zero mortality. The transabdominal approach is safe and effective for the management of Boerhaave's syndrome and should be considered in the treatment paradigm for this condition. Intrathoracic complications account for postoperative morbidity.

Use of interventional radiology in the management of mediastinitis of odontogenic origin

Descending necrotising mediastinitis is a rare complication of odontogenic infection. The key to diagnosis is to maintain a high index of suspicion when antibiotics and adequate surgical drainage do not lead to resolution of symptoms. Open thoracic operation to drain mediastinal collections is potentially lethal and interventional radiological techniques are thought to reduce mortality. We report the use of interventional radiology in the diagnosis, monitoring and treatment of this condition and illustrate our experience with three case reports.

Thoracoscopic Management of a Dermoid Cyst

We report a case of left-sided pleural effusion and mediastinal collection persistently draining pleural fluid through an intercostal drainage tube. Thoracoscopy was planned for evaluation and drainage of mediastinal collection. It revealed a thick-walled mediastinal cyst, which on excision was found to be a dermoid cyst. The patient underwent successful thoracoscopic resection of the dermoid cyst.

Descending Necrotizing Mediastinitis: Ten Years’ Experience

Descending necrotizing mediastinitis is a rare disease that is usually caused by a spreading, diffuse inflammatory reaction (phlegmon) to an odontogenic infection or peritonsillar abscess. Reported mortality rates range from 25 to 40%. The use of antibiotics and advances in resuscitation procedures and critical care techniques have not essentially improved survival, and an effective treatment has not been clearly established. We report the findings of our 10-year study of 21 patients affected by phlegmon and/or fasciitis of the neck. The aim of our contribution is to help define the clinical criteria and diagnostic procedures that will improve the early diagnosis of mediastinal sepsis secondary to neck fasciitis and to suggest optimal treatment approaches. Our experience indicates that (1) cervical drainage alone is sufficient for cases of cervical phlegmon or mediastinal involvement that are limited to a single superior mediastinal space and (2) thoracotomy and drainage of mediastinal collections is necessary when mediastinal sepsis is more extensive.

Recurrent dysphagia after oesophagectomy caused by chylomediastinum

Chylothorax is an uncommon but recognized complication of oesophagectomy. We present a case where there was an isolated mediastinal collection of chyle presenting with recurrent dysphagia.

Non‐vascular thoracic intervention

•. Radiologically guided percutaneous needle biopsy is a safe and well tolerated procedure, which can often be performed as an outpatient procedure.•. Transthoracic needle biopsy is most effective in the diagnosis of malignancy, but has limitations since the likelihood of obtaining a specific benign diagnosis is often low.•. Percutaneous image‐guided aspiration and drainage are fast becoming the “first line” treatments for the management of pleural and mediastinal collections; percutaneous drainage of lung abscess is an acceptable alternative to surgery where medical therapy has failed.•. Tracheobronchial stenting is a valuable (often palliative) technique in the management of airway narrowing.

Spontaneous pneumothorax and pneumomediastinum in IPF.

Patients with idiopathic pulmonary fibrosis (IPF) are at risk for a variety of acute pulmonary complications, including pneumothorax and pneumomediastinum. Our aim was to describe the radiographic and CT findings and to determine the frequency of complicating spontaneous pneumothorax and pneumomediastinum in patients with IPF. A retrospective study was performed including 78 consecutive patients who underwent CT scanning of the chest and who had confirmed IPF. The chest radiographs and CT scans were reviewed by two chest radiologists and classified as showing features of extra-alveolar air collections. The CT scans showed extra-alveolar air in 9 (11.2 %) of 78 patients (six females and three males; age range 26-90 years, mean age 65 years). Pneumothorax was demonstrated in 5 patients and mediastinal air collections in 4 patients. All patients had dyspnea for 1-48 months (mean 14 months). Of the five cases with pneumothorax, four developed acute onset of dyspnea and pleuritic chest pain, whereas 1 patient had a relatively stable functional status. Of the 4 patients with pneumomediastinum, three presented with nonpleuritic chest pain and acute dyspnea. Chest radiographs showed extra-alveolar air in 6 patients. Three cases were predicted to be negative by chest radiographs. Follow-up CT showed that air collections had resolved completely in 5 patients. Two patients died of respiratory failure within 4 months after CT. Extra-alveolar air should be recognized as a relatively common IPF-related complication. Chest CT is a useful imaging method in determining air collections in patients with IPF that become acutely breathless and their chest radiograph fails to reveal the presence of extra-alveolar air.

Descending Necrotizing Mediastinitis Secondary to Pharyngitis: A Case Report

The patient was a 38-year-old female with descending necrotizing mediastinitis (DNM) originating from pharyngitis. The pus from infection by Bacteroides and aerobic streptococci had collected in the anterior and posterior mediastinum and bilateral thoracic cavity. Systemic antibiotic treatment with clindamycin and gentamycin was administered promptly after admission under a diagnosis of DNM, without waiting for results of culture and sensitivity studies. Four puncture drainages were performed by echo-guide to treat bilateral empyema and left upper mediastinal pus collections. Additional surgical drainage via the transcervical approach was performed to drain right upper mediastinal pus. The patient was discharged on hospital day 50, and has since been in good health. Proper drainage at all pus collection sites by echoguide as well as prompt administration of antibiotics directed at both aerobic and anaerobic organisms are essential in the treatment of DNM.

Retrocardiac Pneumomediastinum: Radiographic Finding and Clinical Implications

Fourteen neonates with posterior mediastinal air collections (retrocardiac pneumomediastinum) are described. In the majority of the infants (13 of 14), the mediastinal air developed as a complication of assisted ventilation. It is suggested that the retrocardiac pneumomediastinum represents air trapped in a potential space in the mediastinum posterior to the heart and not within the pulmonary ligament. The collections have a variable shape and size and rarely may produce a tension phenomenon elevating the posterior, inferior portion of the heart off of the diaphragm. There was a strong association of retrocardiac pneumomediastinum with other manifestations of extraalveolar air, including pulmonary interstitial emphysema (13 of 14 infants), pneumothorax (10 of 14 infants), dissection of air into the soft tissues of the neck (10 of 14 infants), and pneumoperitoneum (5 of 14 infants).