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Acute mediastinal conditions

Acute mediastinal conditions. Matevž Srpčič Department of thoracic surgery Surgical clinic University Medical Centre Ljubljana. 0. Introduction. The mediastinum contains vital structures Disturbances here are vitally dangerous Causes can be

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Acute mediastinal conditions

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  1. Acute mediastinal conditions Matevž Srpčič Department of thoracic surgery Surgical clinic University Medical Centre Ljubljana

  2. 0. Introduction • The mediastinum contains vital structures • Disturbances here are vitally dangerous • Causes can be • External (accidental or iatrogenic trauma, infection) • Internal • Perforation of hollow structures (esophagus, airways) • Dilatation/rupture of aorta • Enlargement of normally present structures

  3. 1. Mediastinitis • By far the most common causes are • Esophageal perforation • Surgery • Rarely, infection can spread from adjacent areas. • Acute necrotizing mediastinitis! (descending necrotizing mediastinitis)

  4. 2.1 Acute necrotizing mediastinitis • Life threatening purulent infection • Origin in upper neck • Odontogenic (60-70%) • Peritonsillar • Parapharyngeal • Rapid spread along fascial planes downwards

  5. 2.2 Microbiology • Mixed aerobic and anaerobic infection (synergistic action!) • Usual suspects: • Prevotella, Peptostreptococcus, Fusobacterium, Veillonella, Actinomyces, oral Streptococcus, Bacteroides, Staphylococcus aureus, Hemophilus species, Bacteroides melaninogenicus

  6. 2.3 Less common causes • trauma to the neck, including neck or mediastinal surgery • cervical lymphadenitis and • endotracheal intubation

  7. 2.4 Presentation • Patient being treated for a deep cervical infection • Deteriorates despite antibiotic treatment or even cervical drainage procedures. • General signs of sepsis • Local neck signs of swelling, edema and pain. • Disphagia and dispnoe can develop, but are not necessary for the diagnosis. • 12 hours - 2 weeks after the onset of deep cervical infection • Most commonly within 48 hours

  8. 2.5 Estrera criteria • 1. Clinical manifestations of severe oropharyngeal infection • 2. Demonstration of characteristic radiological features of mediastinitis • 3. Documentation of the necrotizing mediastinal infection at operation or postmortem examination or both • 4. Establishment of the relationship of oropharyngeal infection with the development of the necrotizing mediastinal process • Estrera AS, Landay MJ, Grisham JM, et al: Descending necrotizing mediastinitis. Surg Gynecol Obstet 157:545-552, 1983.

  9. 2.6 Radiographic investigations • Early CT scan!!!

  10. 2.7 Treatment • Antibiotic treatment • Empiric (piperacillin/tazobactame or carbapenem) • Targeted • Surgical drainage and debridment • Cervical drainage ± maxillofacial surgery • Thoracotomy? • YES, if involvement below Th4/carina • YES • Airway management • Tracheostomy?

  11. 2.8 Prognosis • Pre-antibiotic age 50% mortality • Antibiotics improved it only slightly • Last two decades 15 to 33% • High index of suspicion • Early diagnosis • Prompt and aggressive antibiotic, surgical and supportive treatment

  12. 3. Mediastinal haemorrhage • Trauma • Aortic rupture • Thoracic procedures • If time permits, CT angiography (localization, even treatment) • Who do we call? Cardiac or thoracic? • Sternotomy or thoracotomy is used for access and therapy is aimed at evacuating the clot and repairing the underlying lesion

  13. 4. Superior vena cava syndrome • Historically considered a medical emergency • Diagnostic or therapeutic challenge? • Classical presentation of dyspnea (54%), suffusion (54%), cough (29%), and arm or facial swelling (23%) • Onset is most commonly insidious • Causes: thoracic malignancy 95% • Get the diagnosis! • Radiotherapy for NSCLC, chemotherapy for small-cell lung cancer and anticoagulation or thrombolytic therapy for SVC thrombosis

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