Mediastinitis

• • 4 sources

  • 1. Direct contamination

    2. Hematogenous/lymphatic spread (granulomatous)

    3. Extension of infection from neck/retroperitoneum

    4. Extension from lung/pleura

  • Empyema loculates to form paramediastinal abscess; true mediastinal involvement uncommon

  • Mediastinitis often involves pleura

  • Esophageal perforation is most common form of direct contamination (90% of cases)

  • Secondary causes include:

  • -Oral surgery

    -Trauma to pharynx

    -Tracheostomy

    -Mediastinoscopy

    -Thyroidectomy

  • Pneumothorax after upper endoscopy indicates esophageal perforation

Epidemiology

• • Acute: Esophageal, cardiac or other mediastinal operations

  • Rarely, direct infection by suppurative conditions involving ribs or vertebrae

  • Most cases caused by pyogenic organisms

  • Continuous involvement from cervical infection common (along fascial planes)

  • Retroperitoneum less commonly involved

  • Esophageal perforation caused by:

  • -Boerhaave syndrome

    -Iatrogenic trauma (dilation, esophagogastroduodenoscopy, etc)

    -External trauma

    -Cuffed endotracheal tubes

    -Ingestion of corrosives

    -Carcinoma

Symptoms and Signs

• • History of vomiting

  • Severe boring pain in substernal, left or right chest, or epigastric regions, radiation to back

  • Chills, fever, shock, tachycardia

  • Dyspnea, pain in shoulder if involves pleura

  • Swallowing worsens pain; dysphagia

  • 60% have pneumomediastinum/subcutaneous emphysema

  • Pericardial crunching with systole (Hamman sign) is late finding

  • 50% have pleural effusion or hydropneumothorax

  • Neck tenderness, crepitance found in cervical perforation

Imaging Findings

• • Hypaque esophagogram (use water soluble media)

  • CT chest: With PO and IV contrast, may help determine level of perforation, degree of soilage, underlying pathology

Rule Out

• • Myocardial infarction

  • -Often confused with esophageal perforation

• • History and physical exam

  • Hypaque esophagogram (use water soluble media)

  • Chest CT with PO or IV contrast

• • Underlying cause determines treatment

  • Initial management: Immediate drainage of pleural contamination with chest tube

  • Broad-spectrum antibiotics initiated with fluid hydration

Surgery

• • Right thoracotomy: Best access to most of intrathoracic esophagus (including distal portion)

  • Left thoracotomy: Useful for perforation secondary to distal esophageal stricture

  • Iatrogenic perforation (< 24 hrs): 2-layer closure (mucosal layer with interrupted absorbable sutures and muscle closure), buttress with pleura or muscle flap, wide irrigation and drainage

  • Perforations > 48 hrs: Wide drainage, resect esophagus

  • Perforation secondary to cancer, severe reflux stricture, achalasia: Resect esophagus with gastric pull-up if stable and < 24 hrs; if unstable, divert or resect without reconstruction

Indications

• • All intrathoracic leaks should be explored

Medications

• • Broad-spectrum antibiotics (including aminoglycosides)

Prognosis

• • 30-60% mortality with esophageal perforation

References