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: , 1983.

9. 2.6 Radiographic investigations
Early CT scan!!!

10. 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?

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