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 External (accidental or iatrogenic trauma, infection) Internal Perforation of hollow structures (esophagus, airways) Dilatation/rupture of aorta Enlargement of normally present structures

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)

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

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

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

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

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.

2.6 Radiographic investigations Early CT scan!!!

2.7 Treatment Antibiotic treatment Surgical drainage and debridment 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?

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

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

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