Mediastinitis is a serious, often fatal, condition in the chest. Despite the fact that it happens sporadically, it requires special attention and decisive therapeutic actions. What are the causes and symptoms of mediastinitis? How is his treatment going?

Mediastinitisis relatively rare. The data show that there are only a few cases per year per specialist center. Due to the varied etiology and course, we can distinguish several clinical forms. Infectious mediastinitis is divided into:

  • acute mediastinitis- may be limited (mediastinal abscess), spread in a given compartment or run as descending necrotizing mediastinitis
  • chronic mediastinitis

Mediastinitis: causes

The most common cause of acute mediastinitis is a perforation (perforation) of the esophagus (90%). The esophagus is damaged by various mechanisms. Esophageal perforation may occur as a result of:

  • iatrogenic damage - it is usually a complication of esophagoscopy, an endoscopic procedure aimed at examining the esophagus; the complication itself is rare and its incidence does not exceed 0.5%
  • Boerhaave syndrome - spontaneous rupture of the esophagus caused by increased pressure in the esophagus; is associated with the occurrence of intense vomiting, most often after drinking alcohol
  • foreign body ingestion (including after ingestion of corrosive substances)
  • trauma - usually penetrating

The risk of mediastinal inflammation is also related to cardiac surgery. It is usually associated with a median sternotomy - classic surgical access in cardiac procedures. Factors that increase the risk of this complication before surgery include

  1. older age
  2. obesity
  3. big breasts
  4. diabetes
  5. steroid therapy
  6. COPD
  7. condition after radiotherapy

Acute mediastinitis may be a complication of head and neck infections ( descending necrotizing mediastinitis ). They can spread the way descending from, inter alia, cavitiesthe mouth, the throat area through anatomical spaces, e.g. the post-throat space. The most common primary foci are odontogenic infections. Other potential causes may also include: peritonsillar abscess, otitis media, inflammation of the salivary glands, or inflammation of the lymph nodes in the neck.

Mediastinitis can also occur through continuous spread of infection. The source can be, for example:

  • pleural abscess
  • inflammation of the ribs, spine, sternoclavicular joint
  • abdominal abscesses

A different etiology is characterized bychronic mediastinitis . It may be primary or secondary to a pre-existing inflammatory process. Chronic infectious mediastinitis is caused by bacterial and fungal microorganisms. Particularly noteworthy are tuberculous infections ( Mycobacterium tuberculosis ) and histoplasmosis ( Histoplasma capsulatum ), which are the cause of the so-called granulomatous inflammation. The pathway of chronic inflammation can be a process of fibrosis, leading to dangerous consequences. It may also be idiopathic and coexist with other diseases associated with progressive fibrosis, including with retroperitoneal fibrosis or Riedel's goiter.

Worth knowing

The mediastinum is the space that separates both lungs. From the front they are limited by the posterior surface of the sternum, and from the back by the spine. We conventionally divide them into upper and lower mediastinum, in which we can distinguish the anterior, middle and posterior mediastinum. It is here that there are vital organs such as: heart, large vessels, trachea, bronchi, esophagus, phrenic nerve, etc. It is easy to imagine how dangerous inflammation in this area can be.

Mediastinitis: symptoms

The main symptoms of acute mediastinitis include:

  • chest pain (may increase with coughing and breathing)
  • tenderness around the sternum and ribs
  • fever
  • tachycardia - increased heart rate
  • tachypnoe - rapid breathing

The symptoms presented by the patient have a strong relationship with the cause. In the case of esophageal perforation, crackling sounds may appear when the neck and supraclavicular area are pressed. This is a sign of a hypodermic pneumothorax - the presence of air under the skin of the neck. Most often it is a natural consequence of mediastinal pneumothorax (caused by air entering the mediastinum from the esophagus). Descending necrotizing mediastinitis may be associated with symptoms of a head and neck infectionfor example: trismus, toothache, difficulty swallowing or swelling and redness in the neck. Chronic inflammation is usually sparse. Only an extensive process and subsequent filamentation can lead to:

  • narrowing of the airways - shortness of breath, wheezing, strider
  • of the superior vena cava complex
  • strictures of the esophagus - difficulty swallowing
  • stenosis of the mitral valve and pulmonary veins

The most dangerous complication of acute mediastinitis is septic shock, which makes it characterized by a relatively high mortality rate.

Mediastinitis: diagnosis

In addition to the medical history and symptoms that may indicate mediastinitis, imaging tests - X-ray and computed tomography play a very important role. A characteristic find is the widening of the mediastinum with the presence of gas and fluid. In cases caused by oesophageal perforation, pneumothorax, subcutaneous emphysema, and even pneumothorax may appear. It is indispensable to use endoscopic examinations - esophagoscopy in the case of esophageal perforation and bronchoscopy when there is a suspicion of damage to the respiratory tract. Contrasting examination of the esophagus may also be useful (it is important not to use barite pulp for the examination!). The process responsible for chronic mediastinitis requires mediastinoscopy (invasive examination of the contents of the mediastinum) and collection of material for histopathological examination, e.g. in order to exclude the neoplastic process.

Mediastinitis: treatment

Treatment of mediastinitis depends largely on the causative agent. In the event of inflammation resulting from perforation of the esophagus, repair is required. In each case of damage to the thoracic part of the esophagus, it is necessary to insert a gavage and aspirate the gastric contents, as well as broad-spectrum antibiotic therapy.

The applied method of treatment depends on the general condition of the patient, the extent and location of the injury and the time that has elapsed since the perforation.

Surgical treatment of esophageal perforation may involve primary suturing of the esophagus using classical or thoracoscopic access, or sectional resection and reconstruction with the use of an "insert" from a part of the stomach or intestine. Endoscopic methods - the insertion of self-expanding stents - are also used in the supply of perforation (mainly iatrogenic). In exceptional, sporadic cases, conservative treatment is possible - antibiotic therapy and parenteral nutrition.

The key elements of treatmentmediastinitis which is a complication of infections within the head and neck, apart from the use of antibiotics, eliminates the primary focus (e.g. tooth extraction, abscess drainage) and drainage of the fascial spaces of the neck and mediastinum. In the case of chronic fibrosing inflammation, treatment is very difficult. Often it comes down to improving the quality of life and minimizing symptoms by removing the consequences of the fibrosis process - strictures within the esophagus, respiratory tract or large vessels.

Category:

Respiratory system