Mediastinal Extension Research Articles

Function Preserving Surgery for Brachial Plexus Fibromatosis with Mediastinal Extension.

A 54-year-old man with hypertension, end-stage renal disease (ESRD) who was receiving thrice-weekly haemodialysis for the past 3 years, developed breathlessness after a session of haemodialysis. Oxygen saturation by pulse oximetry (SpO2) was 88% and he was admitted for evaluation. Nasopharyngeal swab real time-polymerase chain reaction (RT-PCR) had tested positive for SARS-CoV-2. He was started on intravenous azithromycin, dexamethasone 8 mg, and subcutaneous heparin. On the 8th day after admission, he had painful swelling, redness and watering of the left eye. Within hours, he also complained swelling of the left half of the face, diminished vision and reduced eye movements of the left eye. Magnetic resonance imaging (MRI) and magnetic resonance angiography of the brain revealed left orbital cellulitis. angioinvasive fungal sinusitis. Laboratory testing confirmed the diagnosis. The patient was treated with intravenous ammphotericin B and surgery.

Radiological assessment of a rare potentially lethal acute neck infection in emergency: Ludwig’s angina (A case report)

Ludwig angina is a potentially lethal acute cellulitis of the floor of the mouth and neck, including submandibular, submental and sublingual spaces and ultimately leading to airway obstruction. Computed tomography (CT) of the neck with upper thorax has been used in emergency once the airway obstruction is secured to evaluate the severity of the infection, to assess any abscess and mediastinal extension. Therefore knowledge of imaging features of Ludwig’s angina is essential to ensure an accurate diagnosis and initiation of early treatment. CT also plays an important role in evaluation for need of surgical intervention. However, MRI is superior to CT because of its excellent soft tissue contrast and demonstration of various fascial compartments' involvement.

Pleomorphic sarcoma of the chest wall: A case report

Primary pleomorphic liposarcoma of the chest wall is a rare entity. Most of the reported cases of the chest wall liposarcomas are low grade, well differentiated with mediastinal extension. Majority of these develop from a subcutaneous lipoma. Complete surgical resection is the preferred treatment modality. The benefit of adjuvant radiotherapy or chemoradiotherapy for these tumors is a subject of debate. We report, an unusual case of high grade primary pleomorphic subtype of liposarcoma in a 50-year-old male presenting with a painful swelling in the anterior thoracic wall extending into the pleura but without any mediastinal involvement or distant metastasis.

Successful airway management in a patient with left parapharyngeal and retropharyngeal abscess with mediastinal extension during COVID-19 pandemic

Acute airway compromise caused by a deep neck space abscess significantly contributes to the morbidity and mortality, and it requires quick identification and rapid treatment.1 Parapharyngeal and retropharyngeal abscesses affect 2.64 persons out of 100,000 population. The incidence in males and females is 3.34 and 1.94 per 100,000 people, respectively.2 Of note, the abscess might increase the patient’s susceptibility to COVID-19 infection. In order to limit COVID-19 transmission in such patients, an advanced treatment plan is required.3 We share the anesthetic airway management of a high-risk airway case during the current COVID-19 pandemic.
 Key words: airway management; COVID-19; abscess, parapharyngeal; abscess, retropharyngeal; video-assisted thoracoscopy; Surgery, thoracic
 Citation: Hehsan MR, Shukeri WFWM, Chettiar RSRMS, Abidin HZ. Successful airway management in a patient with left parapharyngeal and retropharyngeal abscess with mediastinal extension during COVID-19 pandemic. Anaesth. pain intensive care 2021;26(1):128-129.
 DOI: 10.35975/apic.v26i1.1784

Risk factors for difficult ventilatory weaning in intensive care patients with cervical cellulitis

PurposeCervical cellulitis is an infrequent but serious infection. The management of the upper airways is difficult, at the actual time of intubation but also regarding the necessity of maintaining mechanical ventilation. The objective of this study is to identify risk factors on admission to the intensive care unit for difficult ventilatory weaning in patients with cervical cellulitis. MethodsBetween January 2013 and December 2018, this retrospective observational study was performed in an intensive care unit with 10 beds in a university hospital recognized as a reference center for the management of cellulitis. All intensive care patients receiving mechanical ventilation after surgery for cervical cellulitis were eligible. Difficult ventilatory weaning was defined as mechanical ventilation lasting more than 7 days or failure of extubation as established by the WIND 2017 study. ResultsWe included 120 patients with severe cervical cellulitis. The median age was 43 years. Eighteen patients (16%) presented mediastinal extension. The risk factor for difficult ventilatory weaning (n = 49) in multivariate analysis was a high level of procalcitonin on admission (OR at 1.14[1.005–1.29]; p<0.042) and the protective factor was surgery in an expert center (OR at 0.11[0.026–0.47]; p<0.003). Eight patients required a tracheotomy in our study: 3 patients during surgery and at a later time for the other 5 of our 8 patients. ConclusionNo intensive care studies have investigated ventilatory weaning risk factors in patients with cervical cellulitis. Yet simple criteria seem to predict this risk. It is now necessary to confirm them by a multicenter prospective study.

S1620 A Symptomatic Posterior Mediastinal Space Pseudocyst Managed by Cystgastrostomy Through a Hiatal Hernia

Introduction: Pseudocysts are seen after acute pancreatitis (AP) and consist of collections of pancreatic secretions surrounded by a fibrous wall. Mediastinal extension of pseudocysts is a rare complication of AP. Here we describe the unique case of a large pseudocyst that extended along a hiatal hernia sac resulting in chest pain and dysphagia, requiring cystgastrostomy in the posterior mediastinal space. Case Description/Methods: A 64-year-old female with a history of a large hiatal hernia (HH) presented to the emergency room (ER) with gradual onset retrosternal pain and associated dysphagia of 1 week duration. She had a recent hospitalization for AP two months earlier. In the ER, vital signs were within normal limits. Cardiac evaluation, complete blood count, and comprehensive metabolic panel were unremarkable. Abdominal computed tomography revealed a 7 x 6.2 cm peripancreatic fluid collection extending through the diaphragm in the posterior mediastinal space, resulting in mass effect on the distal esophagus and HH sac (Figure 1A-C). Upper endoscopy revealed extrinsic-appearing narrowing in the distal esophagus immediately proximal to a 5 cm Hill grade IV HH. Endosonography (EUS) guided cystgastrostomy was successfully performed using a 10 mm x 10 mm electrocautery enhanced lumen apposing metal stent (LAMS). Post-procedure the patient reported symptomatic relief and was admitted for overnight observation. Repeat cross sectional imaging revealed significant reduction in the size of the pseudocyst (Figure 1D). EUS two weeks later revealed complete pseudocyst resolution and the LAMS was removed. Discussion: Mediastinal extension of a pseudocyst is a rare complication of acute pancreatitis. In prior reports, mediastinal pseudocysts have been managed by endoscopic aspiration, placement of plastic stents, or surgical drainage. To our knowledge, this is the first case of a cystgastrostomy performed through a hiatal hernia to drain a pseudocyst in the posterior mediastinum.Figure 1.: Axial (A) and coronal (B and C) views of the CT scan revealed a large pseudocyst extending into the posterior mediastinal space. The sagittal view (D) showed the lumen-apposing metal stent draining the pseudocyst into the hiatal hernia sac.

Rare giant zenker’s diverticulum with mediastinal extension

Zenker’s Diverticulum (ZD) is a herniation of the posterior pharyngeal wall between the inferior pharyngeal constrictor and the cricopharyngeus muscle through a natural weakness [1]. The main clinical presentation is progressive solid food and pill dysphagia, with subsequent weight loss, halitosis, and regurgitation, complicated by the occurrence of several aspiration and recurrent pneumonia when extended into the chest [2,3]. Indeed, only rare few cases of massive mediastinal extension were reported in the literature [3].

外科的介入が遅延し，入院後に多発膿瘍を合併した化膿性胸鎖関節炎の1例(Delayed surgical intervention after admission caused whole body multiple abscesses in the patients with septic arthritis of the sternoclavicular joint: a case report)

要旨化膿性胸鎖関節炎は，胸鎖関節周囲の軟部組織に膿瘍形成を来す疾患で，主に整形外科で扱われるが，敗血症性ショックで救命救急センターに搬入される症例は稀である。今回，外科的介入を含めた集学的治療が必要であった化膿性胸鎖関節炎の1例を経験したので報告する。症例は既往歴にコントロール不良の糖尿病がある49歳の男性。1週間前より左鎖骨痛，その2日後に右肩痛が出現し，徐々に痛みの増悪と意識障害を来し，前医にて敗血症性ショックとなり当院へ救急搬送された。CTでは頸部から胸骨にかけて小さな膿瘍形成を認めた。保存的加療で全身状態の改善が得られ，第9病日には一般病棟へ転床した。その後，炎症反応の再燃があり，第16病日の造影CTで，膿瘍は縦隔に進展し，左前腕部，左膝部，両側大腿骨周囲に膿瘍の形成を認めた。抗菌薬投与に加えて胸腔鏡補助下縦隔ドレナージ術および多発膿瘍に対して開窓術を行い，炎症所見は改善し，第69病日にリハビリ目的に転院となった。頸部領域の膿瘍で胸鎖関節周囲が関与している場合は本疾患を鑑別に挙げ，MRIも踏まえた関節炎・骨髄炎の有無について早期に診断を行い，常に外科的介入を念頭に置いたうえで遅延なく的確に行うことが重要である。

Thoracic mucormycosis in immunocompetent patients

Mucormycosis is an invasive fungal infection. It is rare and commonly associated with fatal outcomes. We report two cases of thoracic mucormycosis in immunocompetent patients. First, is an immunocompetent child with mediastinal mass and extension into the pericardium and left atrium. The second is a young woman with a left pulmonary artery pseudoaneurysm. The first patient could not be salvaged while the second patient was successfully managed with surgical intervention and systemic antifungal treatment. Mucormycosis should be considered as a differential diagnosis in the management of immunocompetent patients in patients with pyrexia of unknown origin and a mediastinal mass. Early and aggressive surgical management along with systemic antifungal treatment improves the survival in this subset of patients.

Mediastinal Extension of Pancreatic Pseudocyst: A Rare Pediatric Presentation

Pancreatic pseudocysts are cystic cavities which are localized collection of pancreatic secretions, rich in amylase and other enzymes, present in and around pancreas, encased in a false epithelial lining of fibrous or reactive granulation tissue. Extension of a pancreatic pseudocyst into the mediastinum is rare. We are reporting a case of a 5-year-old child with mediastinal pancreatic pseudocyst which was successfully drained by cystojejunostomy.

EXTENSIVE CERVICAL NECROTISING FASCIITIS WITH MEDIASTINITIS IN A COVID-19 POSITIVE PATIENT: A CASE REPORT

Necrotising fasciitis is a rapidly progressing soft tissue infection associated with significant morbidity and mortality. We present a case of cervical necrotising fasciitis with mediastinal extension in a diabetic young male who was COVID-19 positive. He presented with a five-day history of left-sided neck swelling which was fluctuant, red and painful. Subsequent debridement and management of the wound were complicated by the comorbid SARS-CoV2 infection due to potential need for proning. This case highlights the complex interplay between the management of two significant conditions; the surgical approach to necrotising fasciitis and the concern of deterioration due to COVID-19.

RARE PRESENTATION OF MEDIASTINAL ABSCESS SUPERINFECTION IN AN INFLUENZA B PATIENT

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Influenza is generally a self-limited infection, however complicated with bacterial superinfection, it has been associated with increased morbidity and mortality[1]. We present the first case report in the literature of an immunocompetent Influenza B patient complicated with methicillin-sensitive Staphylococcus aureus (MSSA) mediastinal abscess and necrotizing pneumonia. CASE PRESENTATION: A 33-year-old male patient with past medical history of asthma presented to ED with myalgias, productive cough with rusty sputum and intermittent low-grade fever for 2 weeks. Initial vitals showed temperature of 100.6 F, heart rate of 106 bpm, respiratory rate of 24 with normal blood pressure and oxygen saturation. Physical examination was unremarkable. Initial workup revealed leukocytosis with WBC of 18 k/ul. CXR showed asymmetric enlargement of the right hilum with suspicion of central mass and to further analyze CT Chest with IV contrast was done showing consolidation in the right lower lobe (RLL) with mass-like consolidation in right hilum with mediastinal extension. (Figure 1) Patient was treated empirically with Piperacillin/Tazobactam, Vancomycin and Azithromycin. Nasopharyngeal swab for Influenza B PCR came back positive and blood cultures grew MSSA after which antibiotics were de-escalated to Oxacillin. His hospital course was complicated by clinical deterioration and repeat CT Chest revealed RLL Necrotizing Pneumonia and anterior mediastinal abscess. (Figure 2) He had emergent median sternotomy with radical thymectomy and debridement of mediastinal tissues. No histological evidence of malignancy was present, and cultures grew MSSA. He improved clinically and was discharged on IV oxacillin course for 6 weeks. His follow up CT chest showed complete resolution of mediastinal and resolving RLL infiltrate. DISCUSSION: Pneumonia is considered the most common complication of influenza. It could be primary viral pneumonia or secondary to bacterial superinfection due to epithelium disruption and alteration in host immunity response. Mediastinal abscess has not been reported before in the literature as post influenza complication. Our case is first in literature for such life-threatening complication and the key to success is early imaging detection, keeping high level of suspicion when the patient is not responding appropriately to the initial therapy and aggressive surgical and medical management. CONCLUSIONS: Clinical deterioration or inappropriate response to antibiotic therapy in post influenza bacterial pneumonia should raise the suspicion for uncommon complications such as mediastinal abscess and should be investigated with advanced imaging, CT chest with IV contrast or MRI. Reference #1: Martin, C.M., et al., Asian influenza A in Boston, 1957-1958. I. Observations in thirty-two influenza-associated fatal cases. AMA Arch Intern Med, 1959. 103(4): p. 515-31. DISCLOSURES: No relevant relationships by Saira Afzal, source=Web Response No relevant relationships by Mahmoud Alwakeel, source=Web Response No relevant relationships by kuttetoor Gopalakrishna, source=Web Response No relevant relationships by Talha Saleem, source=Web Response

Pleural effusion with rapid refill: A diagnostic dilemma-series of five cases

Background: A rare complication of acute or chronic pancreatitis is the formation of a mediastinal pancreatic pseudocyst (MPP). Inflammatory injury causes pancreatic ductal disruption leading to leakage of amylase rich pancreatic secretions along the paths of minimum resistance. Thoracopancreatic fistulae are caused by the posterior disruptions while anterior disruptions can cause pancreatic ascites. Patients of pancreatitis can present with symptoms like chest pain, respiratory distress, dysphagia and in extreme cases with pericardial effusion and tamponade. High index of suspicion is needed in diagnosing this condition. Here, we report the imaging characteristics of five such cases. Our results revealed three features in common: (i) extension of pancreatic pseudocyst into the mediastinum; (ii) rapid refill of pleural effusions; and (iii) imaging findings consistent with pancreatitis. Aims: 1) To evaluate the cause of rapid refill of pleural effusion in cases of acute or chronic pancreatitis with pseudocysts. 2) To evaluate the mediastinal extension of the pseudocyst.Materials and Methods: Patients with rapid refill of pleural effusion were sent to the department of surgery and subsequently to radiology for further evaluation. Chest radiographs, diagnostic and therapeutic tap, abdominal ultrasonography, barium swallow and contrast enhanced CT scans of thorax and abdomen were done. Result: All our five patients of pancreatitis with rapid refill of pleural collection were found to have mediastinal extension of the pancreatic pseudocyst with pancreatico-pleural fistula.Conclusion: Mediastinal extension of the pancreatic pseudocyst with pancreatico-pleural fistula is a rare complication following acute or chronic pancreatitis. Detailed radiological investigations are a useful adjunct to surgical management.

MON-451 An Unusual Case of Follicular Thyroid Cancer with Pulmonary Metastasis and Concurrent Hyperthyroidism

Introduction: Follicular Thyroid Cancer (FTC) accounts for approximately 12 % of all thyroid cancers and is the second most common cause of differentiated thyroid cancer. However, coexisting hyperthyroidism and thyroid malignancy is considered a rare event and is thought to have a prevalence of 0.21–9.0 %. We describe a compelling case of metastatic FTC initially presenting with subclinical hyperthyroidism progressing to overt hyperthyroidism.Clinical Case: An 88-year-old man with a history of prostate cancer, previous tobacco dependence, and hypertension initially presented with complaints of a chronic non-productive cough associated with unintentional weight loss and fatigue. Initial imaging included a chest CT that showed several bilateral pulmonary nodules suspicious for metastatic disease, as well as an enlarged left-sided thyroid mass, which extended from the inferior pole into the mediastinum. FDG PET/CT showed avid disease identified in the lung. CT-guided lung biopsy was performed, and histopathology revealed FTC. Thyroid function tests (TFTs) revealed a Tg level of 1427 (0.00–33.70), TgAb <1.0 (< 13.6), TSH 0.05 (0.40–4.50), FT4 1.1 (0.8–1.8) and FT3 3.4 (2.3–4.2). Biochemical testing was consistent with subclinical hyperthyroidism. Neck ultrasound showed bilateral thyroid nodules, the largest located on the left mid-pole measuring 3.4 x 3.2 x 3.7 cm. He underwent a whole-body I-131 diagnostic scan, which showed intense uptake of the radionuclide within the thyroid gland, more evident on the left, but additional metastatic lesions elsewhere in the visualized body were not possible. TFTs were repeated, which showed a TSH of 0.01, FT4 of 2.0, and FT3 of 6.4. He was subsequently started on methimazole daily and eventually became euthyroid. Due to advanced age, significant mediastinal extension, and lung metastasis, the patient was not a candidate for surgical resection and treatment with a targeted tyrosine kinase inhibitor. He ultimately opted for an observational approach.Conclusion: Although metastatic FTC carries a poor prognosis, concurrent hyperthyroidism is thought to be associated with a more aggressive disease course and higher mortality compared to differentiated thyroid cancers in euthyroid patients.Sources: 1. Pazaitou-Panayiotou, K., Perros, P., Boudina, M., Siardos, G., Drimonitis, A., Patakiouta, F., & Vainas, I. (2008). Mortality from thyroid cancer in patients with hyperthyroidism: the Theagenion Cancer Hospital experience, European Journal of Endocrinology, 159(6), 799–803.2. Benjamin Momo Kadia, Christian Akem Dimala, Ndemazie Nkafu Bechem, Desmond Aroke. BMC Res Notes. 2016; 9: 369.3. Parameswaran R, Shulin Hu J, Min En N, Tan WB, Yuan NK. Patterns of metastasis in follicular thyroid carcinoma and the difference between early and delayed presentation. Ann R Coll Surg Engl. 2017;99(2):151–154.

Pancreatic Pseudocyst with Mediastinal Extension Presenting as Pseudo-Kirklin Sign—Multimodality Imaging

AbstractA mass lesion of the gastric cardia or fundus causing an alteration in the normal regular, translucent gastric fundal air shadow on a frontal erect chest radiograph is referred to as “the Kirklin sign.” Here we present “Pseudo-Kirklin sign” observed on the frontal radiograph of a 46-year-old male patient due to a soft tissue shadow/contour deformity of the fundal gas shadow caused by pseudocyst of the pancreas. We evaluated the patient using plain radiography, contrast enhanced computed tomography, magnetic resonance imaging, and endoscopic ultrasound (EUS) with the cyst drained under EUS guidance. So far only two cases of mediastinal pseudocysts have been drained successfully by EUS-guided aspiration.

Humongous mediastinal goiter: Interesting case report with its management challenges

Goiters with mediastinal extension are very rare. Occasionally they necessitate thoracic exploration for complete surgical excision which may be associated with serious complications. A 50-year-old man presented with a simple multinodular goiter and huge thoracic extension. After adequate investigative workup and optimal preoperative preparation, he underwent successful total thyroidectomy via combined cervicotomy and complete sternotomy. The excised goiter was 1.85 kg in weight and 20 × 25 × 18 cm in dimensions occupying entire anterosuperior mediastinum and 60% of left pleural cavity. Postoperative recovery was uneventful with no major morbidity. Rarely, giant thoracic extensions such as this case can be encountered. We are arguably reporting one of the largest thoracic goiters ever reported.

Value of computed tomography evaluation in the detection of cardio-pericardial lymphomatous involvement

Leukemia and malignant lymphoma are most likely to involve the cardiac chambers and pericardium, often by contiguous direct extension from a mediastinal mass. Our study’s objective is to discuss and illustrate computed tomography (CT) findings in both cardiac and pericardial involvement in patients diagnosed with a hematologic malignancy and radiologic evidence of a mediastinal mass. We reviewed our database for a period of ten years (between January 2010 and March 2020) and we selected four patients with radiologic evidence of a mediastinal mass and tumoral extension in cardio-pericardial struc­tures, in the context of a hematologic malignancy. All our patients have been investigated by CT and were diagnosed with non-Hodgkin lymphoma. In three cases, we found intraatrial extension of the tumoral mass, in one case with both atria affected. Tumoral encasement and obstruction of the superior pulmonary veins were noted in two cases, and CT signs of superior vena cava syndrome (SVCS) were noted in two cases with direct invasion and venous com­pres­sion by the tumoral mass. CT is an investigation de­di­ca­ted to the evaluation of cardio-pericardial tumoral ex­ten­sion in cases of malignant hematological disease, allowing to detect the extent of tumoral involvement or to assess tho­ra­cic emergency conditions (SVCS cardiac tamponade, pul­mo­na­ry embolism).

Mediastinal Access for Oral and Maxillofacial Surgeons

Introduction Cardiothoracic surgical access to the mediastinum may rarely be required in the management of Oral and Maxillofacial surgical cases. Examples of such cases include of mediastinal extension of odontogenic fascial space infection and neoplastic neck disease, e.g. ectopic parathyroid adenoma, mediastinal cystic hygroma and retrosternal goitre. We present a series of cases where median sternotomy and thoracoscopic approach were required for mediastinal dissection.

A rare case of huge retrosternal goiter

Retrosternal goiter is defined when more than or equal to 50% of the thyroid mass is below the thoracic inlet. A median sternotomy approach is required in selected cases especially those presenting with long standing history and radiological assessment is suggestive of thoracic component larger than thoracic inlet. The case reported by us was a 65 year old lady with huge retrosternal goiter with history of dyspnea. Her contrast-enhanced computed tomography neck and thorax suggested diffuse enlargement of both lobes with mediastinal extension and pressure effects in the form of luminal narrowing of trachea. A total thyroidectomy was performed with median sternotomy. No post-operative complications occurred and patient was discharged on 6th post-operative day. Histopathology suggested multinodular goiter.

Giant Cystic Pancreatic Lymphangioma with Mediastinal Extension: A Case Report and Review of the Literature

Lymphangioma is an infrequent benign tumour that is formed usually from a congenital malformation of the lymphatic ducts causing lymphangiectasis. The abdominal location represents 1-5%, with dominance in the mesentery and retroperitoneum, however, the pancreatic location is very rare having described less than 100 cases published worldwide. The clinical symptoms of the lymphangiomas are non-specific and depend of the tumour’s size and location. Here we present a clinical case of a pancreatic lymphangioma with mediastinal extension who was treated with a complete resection and this case shows that the diagnosis of cystic pancreatic lymphangioma must be taken as a differential diagnosis of pancreatic cystic lesions.